Juta's Manual of Nursing, Volume 1: Fundamental and General Nursing [3 ed.] 9781485117858, 1485117852

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Third edition

Nursing care remains at the cutting edge of science as innovations in patient care continuously evolve. However, fundamental and general skills are still necessary to develop the clinical reasoning skills a nurse requires in order to provide safe, high-quality care to patients and communities. Suitable for the Staff Nurse, Professional Nurse and Nursing Auxiliary qualification, Juta’s Manual of Nursing Volume 1: Fundamental and General Nursing has been updated to ensure that it meets the requirements of the new qualifications for Fundamental and General Nursing. All chapters include updated information where appropriate. New topics include the latest methods in infection control, information on electronic patient records, the ethical use of social media and a review of nutritional information. Each chapter contains: • The prerequisite knowledge necessary for study of that chapter, to ensure integration with other core subjects • Ethical considerations • Relevant medico-legal considerations • Key concepts and terminology as well as new vocabulary.

Skills videos of selected procedures are available to prescribing institutions

Third edition

Juta’s Manual of Nursing Volume 1 Fundamental and General Nursing

N Geyer, SM Mogotlane A Young, H Boshoff ME Chauke, MC Matlakala JD Mokoena, LP Naicker MB Randa

The well-known and respected team of authors from previous editions have drawn on their years of practical and theoretical experience to produce a comprehensive and up-to-date text for the South African nursing environment.

Fundamental and General Nursing

Fundamental and General Nursing

Juta’s Manual of Nursing Volume 1

Juta’s Manual of Nursing Volume 1

Third edition

Contact: [email protected]

www.jutaacademic.co.za

N Geyer, SM Mogotlane, A Young, H Boshoff, ME Chauke MC Matlakala, JD Mokoena, LP Naicker, MB Randa

Juta’s Manual of Nursing Volume 1 Fundamental and General Nursing

Third edition Editors Nelouise Geyer Sophie Mogotlane Anne Young

Contributors Hananja Boshoff Motshedisi Chauke Mokgadi Matlakala Joyce Mokoena Peggy Naicker Moreoagae Randa

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Juta’s Manual of Nursing, Volume 1: Fundamental and General Nursing First published 2003 Second edition 2009 Revised reprint 2010 Third edition 2016 Juta and Company (Pty) Ltd PO Box 14373, Lansdowne 7779, Cape Town, South Africa © 2016 Juta & Company (Pty) Ltd ISBN 978-1485-11381-2 (Print) ISBN 978-1485-11785-8 (WebPDF) This book is copyright under the Berne Convention. In terms of the Copyright Act 98 of 1978, no part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without permission in writing from the publisher. Project Manager: Carlyn Bartlett-Cronje Copy editor: Wendy Priilaid Proofreader: Pat Hanekom Book design and DTP: Lebone Publishing Services, Cape Town Cover design: Eugene Badenhorst Index: Michel Cozien Disclaimer In the writing of the book, every effort has been made to present accurate and up-to-date information from the best and most reliable sources. However, the results of nursing individuals depend on a variety of factors that are beyond the control of the authors and publishers. Therefore, neither the authors nor the publishers assume responsibility for, nor make any warranties with regard to the outcomes achieved from the procedures described in this book.

Contents Preface ............................................................................................................................ xxii Acknowledgements ....................................................................................................... xxiii About the authors ......................................................................................................... xxiv

Section 1: Fundamental nursing science Chapter 1: Introducing nursing ..................................................... 3 Introduction .................................................................................................................. 3 Historical perspectives ................................................................................................. 4 The images of nursing ............................................................................................ 5 Nursing in South Africa before 1900 ................................................................... 7 Nursing in South Africa in the 20th century ...................................................... 9 Training of black nurses ........................................................................................ 9 Highlights in nursing development after 1950 ................................................... 9 The meaning of nursing .............................................................................................. 10 Selected theories of nursing ........................................................................................ 11 Components common to nursing theories ........................................................... 12 An overview of selected nursing theories ........................................................... 13 Theories and the nursing process ......................................................................... 16 Models for nursing the individual, family or community.................................. 16 Stages of the life cycle and the role of nurses .......................................................... 16 The health–ill-health continuum and the role of nurses ......................................... 18 The agent–host–environment model .................................................................... 19 The health-belief model ......................................................................................... 20 Illness and disease .................................................................................................. 20 Social factors that influence disease .................................................................... 21 The sick role ............................................................................................................ 22 Approaches to healthcare delivery systems in South Africa .................................. 23 Healthcare services in South Africa............................................................................ 24 The national health system ................................................................................... 24 The public healthcare system ................................................................................ 25 The private sector healthcare system.................................................................... 25 Non-governmental organisations ......................................................................... 26 Conclusion ..................................................................................................................... 26 Suggested activities for students ................................................................................ 26

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Chapter 2: Practising the profession of nursing within the South African professional legal framework  ......................................................................................................... 28 Introduction ................................................................................................................... 32 The professional status of nursing ............................................................................. 32 The meaning of professionalism ........................................................................... 33 Criteria for the professional status of nursing and midwifery in South Africa ............................................................................................................ 33 Criteria for recognition as a profession ............................................................... 34 Professional conduct of nurses ................................................................................... 35 The South African legal framework for nurses and midwives ............................... 36 The social contract in nursing and midwifery .................................................... 36 The importance of legal recognition of the nursing profession ....................... 37 Contractual obligations in the workplace ........................................................... 37 The content of the National Health Act 61 of 2003 ........................................... 38 The content of the Nursing Act 33 of 2005 .............................................................. 39 Regulations, codes and rules relating to nursing practice ...................................... 43 Government Notice R2598: Regulations relating to the scope of practice of persons who are registered or enrolled under the Nursing Act .... 43 Government Notice R767: Rules setting out the acts or omissions in respect of which the Council may take disciplinary steps ................................ 46 Code of Ethics for nursing practitioners in South Africa .................................. 51 Professional associations and organisations ............................................................. 51 Trade unions .................................................................................................................. 51 Functions of a professional association/organisation ....................................... 52 Professional indemnity .......................................................................................... 53 Industrial action ...................................................................................................... 53 Conclusion ..................................................................................................................... 54 Suggested activities for students ................................................................................ 54

Chapter 3: Practising the profession of nursing within the South African professional-ethical framework .... 55 Introduction ................................................................................................................... 58 The philosophical basis of nursing ............................................................................. 58 Philosophical schools of thought ......................................................................... 59 Introductory ethics ....................................................................................................... 63 Ethics ........................................................................................................................ 63 The science of ethics .............................................................................................. 63

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Morals ....................................................................................................................... 65 Values ....................................................................................................................... 65 Ethos ......................................................................................................................... 67 Ethical principles in nursing ....................................................................................... 67 Beneficence .............................................................................................................. 67 Justice ....................................................................................................................... 68 Autonomy ................................................................................................................ 68 Veracity .................................................................................................................... 68 Fidelity ..................................................................................................................... 68 Ethical decision making ............................................................................................... 68 Ethical responsibility of the nurse .............................................................................. 69 Liability, responsibility and accountability ......................................................... 70 Nursing as a service to humankind ............................................................................ 71 Duty to take care ..................................................................................................... 72 Human rights ........................................................................................................... 72 Rights of the patient ............................................................................................... 73 Rights of the nurse ................................................................................................. 75 Bullying in the health sector ................................................................................. 76 Patient advocacy ..................................................................................................... 76 Informed consent .................................................................................................... 77 Period of validity of consent ................................................................................. 78 Giving consent ........................................................................................................ 78 Procedure or treatment .......................................................................................... 79 Ethical dilemmas ........................................................................................................... 79 Sanctity of life versus quality of life ................................................................... 79 Codes of ethics in nursing ........................................................................................... 80 The Florence Nightingale Pledge .......................................................................... 81 International Council for Nurses (ICN) Code of Ethics for Nurses ................... 81 The South African Nurses’ Code of Service ........................................................ 82 The meaning of the Lamp in the pledge of service ............................................ 83 Conclusion ..................................................................................................................... 83 Suggested activities for students ................................................................................ 84

Chapter 4: Information management ..................................... 85 Introduction ................................................................................................................... 87 Standards for an information management system ................................................. 88 Managing patient information .................................................................................... 89 Supporting information ......................................................................................... 89

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The need to generate and maintain patient information .................................. 91 Confidentiality and access to records .................................................................. 92 The role of the nurse .............................................................................................. 93 Manual record keeping .......................................................................................... 94 Principles of good record keeping ........................................................................ 94 Incident reports ....................................................................................................... 95 Electronic management of patient information ................................................. 96 The benefits of electronic patient records ........................................................... 96 Challenges of electronic records and databases ................................................. 97 Conclusion ..................................................................................................................... 98 Suggested activities for students ................................................................................ 98

Chapter 5: Introducing the concept of bio-psychosocial needs ........................................................................... 99 Introduction ................................................................................................................... 100 Bio-psychosocial theories ............................................................................................ 100 Nancy Roper ............................................................................................................ 101 Hildegard Peplau ..................................................................................................... 101 Abraham Maslow .................................................................................................... 101 Physical needs ............................................................................................................... 102 Need for oxygen ..................................................................................................... 102 Need for circulation ................................................................................................ 102 Need for fluids and electrolytes ............................................................................ 103 Need for nutrition ................................................................................................... 103 Need for elimination of waste products ............................................................... 103 Need for temperature regulation ........................................................................... 103 Need for mobility and exercise ............................................................................. 103 Need for hygiene ..................................................................................................... 104 Need for comfort and rest ...................................................................................... 104 Need for safety ........................................................................................................ 104 Need for security ..................................................................................................... 104 Need for sexuality ................................................................................................... 105 Psychosocial needs ....................................................................................................... 105 Need for cognition .................................................................................................. 105 Need for adaptation ................................................................................................ 105 Need for self-esteem and self-concept ................................................................. 106 Need for autonomy ................................................................................................. 106 Need for relatedness ............................................................................................... 105

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Need for stimulation ............................................................................................... 107 Need for communication ....................................................................................... 107 Spiritual needs .............................................................................................................. 107 Need for meaningfulness ....................................................................................... 107 Need for religious expression ................................................................................ 108 Conclusion ..................................................................................................................... 108 Suggested activities for students ................................................................................ 108

Chapter 6: Recognising spiritual needs ................................. 110 Introduction ................................................................................................................... 111 Spirituality and religion .............................................................................................. 112 Meeting the spiritual needs of patients ..................................................................... 112 Principles of spiritual care ........................................................................................... 115 Nursing competencies for spiritual care .................................................................... 115 Need for religious expression ...................................................................................... 116 Belief systems of the major religions ......................................................................... 116 Christianity............................................................................................................... 116 Judaism..................................................................................................................... 118 Islam ......................................................................................................................... 121 Hinduism .................................................................................................................. 122 Buddhism ................................................................................................................. 124 Traditional African Religion .................................................................................. 126 Conclusion ..................................................................................................................... 133 Suggested activities for students ................................................................................ 133

Chapter 7: Practising nursing within a culturally diverse society ................................................................................................. 135 Introduction ................................................................................................................... 136 The concept of culture ................................................................................................. 137 The importance of culture ........................................................................................... 137 The acquisition of cultural knowledge and understanding ............................... 138 Cultural issues in healthcare........................................................................................ 138 Diet ........................................................................................................................... 138 Hygiene practices .................................................................................................... 139 Family hierarchy and lines of communication ................................................... 139 Disposal of body parts ........................................................................................... 139 Death, dying and the disposal of the body ......................................................... 140 Amulets and charms ............................................................................................... 140

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The role of women .................................................................................................. 141 Sexuality .................................................................................................................. 141 Cultural perspectives on health and illness ............................................................... 141 The magico-religious paradigm............................................................................. 141 The biomedical paradigm ...................................................................................... 142 The holistic paradigm ............................................................................................. 142 Collaborative, comprehensive and/or alternative healthcare provision ................ 143 A nurse’s interface with different cultures ................................................................ 144 Communication in a cultural context ........................................................................ 144 A nurse’s role within the multidisciplinary team from a cultural perspective. 146 Conclusion ..................................................................................................................... 147 Suggested activities for students ................................................................................ 147

Chapter 8: Community assessment ............................................ 148 Introduction ................................................................................................................... 149 The meaning of community ........................................................................................ 150 The meaning of community assessment .............................................................. 150 Research and community assessment ........................................................................ 153 Participatory and action research ......................................................................... 154 Process of community assessment ....................................................................... 156 Steps in community assessment ........................................................................... 157 Community diagnosis .................................................................................................. 160 Interventions ................................................................................................................. 161 Planning ................................................................................................................... 161 Implementation ....................................................................................................... 161 Evaluation ................................................................................................................ 161 Conclusion ..................................................................................................................... 162 Suggested activities for students ................................................................................ 162

Chapter 9: Patient assessment ....................................................... 163 Introduction ................................................................................................................... 165 Reasons for patient assessment .................................................................................. 165 Assessing a patient ....................................................................................................... 166 Taking a patient’s history ...................................................................................... 166 Approach to the patient during history taking ................................................... 166 The physical examination ........................................................................................... 169 Approach to the patient ......................................................................................... 170 Techniques used during the physical examination ............................................ 170

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Diagnostic tests ............................................................................................................. 173 Measurement of electrical activity ....................................................................... 174 Visualisation techniques ........................................................................................ 174 Radiographic techniques ........................................................................................ 176 Nuclear techniques ................................................................................................. 177 Tomography ............................................................................................................. 177 Ultrasonography ..................................................................................................... 177 Magnetic resonance imaging ................................................................................ 178 Laboratory studies ........................................................................................................ 178 Conclusion ..................................................................................................................... 179 Suggested activities for students ................................................................................ 179

Chapter 10: Planning nursing care ............................................ 180 Introduction ................................................................................................................... 182 Planning nursing care .................................................................................................. 182 Activities involved in planning nursing care ...................................................... 183 Implementation of a care plan .............................................................................. 188 Evaluation of a care plan ...................................................................................... 189 Conclusion ..................................................................................................................... 190 Suggested activities for students ................................................................................ 190

Chapter 11: Home- and community-based care ........... 192 Introduction ................................................................................................................... 193 Home- and community-based care defined .............................................................. 194 Essential elements of home- and community-based care ....................................... 194 Goals of home- and community-based care ............................................................. 195 Advantages of home- and community-based care .................................................. 195 Discharge plan .............................................................................................................. 196 Process of discharge planning .............................................................................. 197 Implementation of the plan ................................................................................... 199 The team involved in home- and community-based care ...................................... 202 The role of the primary caregiver ......................................................................... 202 The role of the nurse............................................................................................... 202 The role of the doctor ............................................................................................. 203 The role of the social worker ................................................................................. 203 The role of the nutritionist .................................................................................... 203 The role of community health workers/volunteers ............................................ 203 The role of support groups .................................................................................... 203

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Provision of home- and community-based care ...................................................... 204 Procedures followed during home care ............................................................... 204 Basic nursing care .................................................................................................. 205 Caring for the caregiver ......................................................................................... 207 Terminal care ................................................................................................................. 207 Technology in home care ....................................................................................... 207 Hospice care ............................................................................................................ 207 Respite care .............................................................................................................. 207 Conclusion ..................................................................................................................... 207 Suggested activities for students ................................................................................ 208

Chapter 12: Maintaining patient safety ............................... 210 Introduction ................................................................................................................... 212 Overview of general aspects of safety in a healthcare institution.......................... 212 Patient safety in the healthcare institution................................................................ 212 Nursing and safety ................................................................................................. 212 National standards of patient safety .................................................................... 213 Patient safety, clinical governance and clinical care ......................................... 214 International standards of patient safety in nursing practice .......................... 215 Common safety issues in healthcare .......................................................................... 216 Factors affecting patients’ potential for accidents ............................................. 216 Identification and management of risks in the healthcare environment .............. 218 Existing safety knowledge ..................................................................................... 218 Identification and management of risks .................................................................... 219 Infections ................................................................................................................. 219 Safe administration of medication ....................................................................... 222 Principles of safe administration of medication ................................................. 222 Safe storage and control of medications ............................................................. 224 Poisons ..................................................................................................................... 224 Falls .......................................................................................................................... 225 Restraints ................................................................................................................. 226 Safety of the person, reputation and possessions of patients ................................. 228 On admission ........................................................................................................... 228 Kitting of clothes to be locked in a kit cupboard/room .................................... 229 Care of money and valuables ................................................................................ 229 Unconscious or disoriented patients .................................................................... 229 Patients going to theatre ........................................................................................ 229 Conclusion ..................................................................................................................... 229

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Suggested activities for students ................................................................................ 230

Chapter 13: Infection control in the unit ........................... 231 Introduction ................................................................................................................... 233 Pathophysiology of infection ...................................................................................... 234 Chain of infection ................................................................................................... 234 Mode of transmission of infection ....................................................................... 234 Risk factors for infection ....................................................................................... 235 Hospital-acquired infections ................................................................................. 235 Principles of infection control .............................................................................. 236 Guidelines for infection control ............................................................................ 236 Contact precautions ................................................................................................ 236 Droplet precautions ................................................................................................ 236 Airborne precautions .............................................................................................. 237 Methods of infection prevention and control ..................................................... 237 Hand washing ......................................................................................................... 239 Infection-control actions ....................................................................................... 240 Conclusion ..................................................................................................................... 241 Suggested activities for students ................................................................................ 241

Chapter 14: Communicating and teaching ........................ 242 Introduction ................................................................................................................... 244 Principles of communication....................................................................................... 244 Communication in healthcare settings ...................................................................... 245 Functions of health communication .................................................................... 245 Key features of health communication ................................................................ 245 Therapeutic relationships ....................................................................................... 247 Patient teaching ............................................................................................................ 247 Principles of teaching ............................................................................................. 247 Evaluation ................................................................................................................ 251 Record keeping ........................................................................................................ 252 Conclusion ..................................................................................................................... 252 Suggested activities for students ................................................................................ 252

Chapter 15: Caring for the needs of the nurse ............. 254 Introduction ................................................................................................................... 255 The need for an identity .............................................................................................. 256 The need for a personal identity ........................................................................... 256

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The need for a collective identity ......................................................................... 257 The need for recognition ............................................................................................. 258 Social recognition ................................................................................................... 258 Financial recognition ............................................................................................. 258 Other recognition from the employer .................................................................. 258 Need for recognition of nurses’ rights ................................................................. 259 Inter-professional recognition .............................................................................. 259 The need for support..................................................................................................... 259 Support in the workplace ...................................................................................... 259 Personal support systems ....................................................................................... 260 The need for protection ............................................................................................... 261 The rights of the nurse that require protection ................................................... 261 Needs of the nurse in terms of collective action................................................. 266 Conclusion ..................................................................................................................... 268 Suggested activities for students ................................................................................ 268

Chapter 16: Basic life skills for the nurse ........................... 269 Introduction ................................................................................................................... 270 Attributes of life skills ................................................................................................. 271 Self-analysis ............................................................................................................ 271 Communication ............................................................................................................. 275 Factors that influence communication................................................................. 275 The communication process .................................................................................. 276 Forms of communication ....................................................................................... 277 Potential barriers to communication .................................................................... 278 Decision making ........................................................................................................... 279 Problem solving ............................................................................................................ 281 Seeking alternatives ............................................................................................... 282 Making the decision................................................................................................ 282 Implementing chosen strategy and tactics .......................................................... 282 Evaluating the outcomes ....................................................................................... 282 Using functional thought ....................................................................................... 283 Assertive behaviour ...................................................................................................... 284 Empathy ......................................................................................................................... 288 Conflict management ................................................................................................... 291 Coping with stress ........................................................................................................ 293 How to manage stress ............................................................................................ 293 Time management ........................................................................................................ 294

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Interviewing and counselling ..................................................................................... 296 Conclusion ..................................................................................................................... 297 Suggested activities for students ................................................................................ 297

Section 2: General nursing science Chapter 17: Oxygen need ................................................................... 301 Introduction ................................................................................................................... 304 Normal factors influencing respiration ...................................................................... 305 The process of breathing ........................................................................................ 305 Respiration ............................................................................................................... 305 Causes of inadequate oxygenation of cells and tissues ........................................... 305 Nursing assessment of respiratory function .............................................................. 306 Patient history ......................................................................................................... 306 Physical examination ............................................................................................. 307 Nursing implications .............................................................................................. 311 Diagnostic tests ....................................................................................................... 312 Common respiratory problems .................................................................................... 314 Cough ....................................................................................................................... 314 Dyspnoea ................................................................................................................. 318 Haemoptysis ............................................................................................................ 320 Cyanosis ................................................................................................................... 320 Acute respiratory failure ........................................................................................ 320 Oxygen therapy ............................................................................................................ 322 Systems for the delivery of oxygen ..................................................................... 323 Humidification systems .......................................................................................... 330 The artificial airway ............................................................................................... 331 Nursing implications .............................................................................................. 335 Conclusion ..................................................................................................................... 335 Suggested activities for learners ................................................................................. 335

Chapter 18: Circulation need .......................................................... 337 Introduction ................................................................................................................... 340 Function of the circulatory system ............................................................................ 340 The heart................................................................................................................... 341 The arteries .............................................................................................................. 341 The arterioles ........................................................................................................... 342 Capillaries ................................................................................................................ 342

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Veins.......................................................................................................................... 342 Blood pressure ......................................................................................................... 342 Nursing assessment of circulatory function .............................................................. 343 Taking the pulse ...................................................................................................... 343 Taking the blood pressure ...................................................................................... 344 Temperature ............................................................................................................. 344 Urine output and fluid balance ............................................................................. 344 Electrocardiogram (ECG) ........................................................................................ 344 Pulse oximetry ........................................................................................................ 344 Common circulatory or cardiovascular problems .................................................... 345 Blood pressure ......................................................................................................... 345 Hypertension ........................................................................................................... 345 Hypotension ............................................................................................................ 347 Abnormal cardiac rhythm ..................................................................................... 349 Conclusion ..................................................................................................................... 349 Suggested activities for students ................................................................................ 349

Chapter 19: Temperature regulation need ......................... 351 Introduction ................................................................................................................... 353 Temperature and the mechanisms of heat production and heat loss .................... 353 Heat production ...................................................................................................... 353 Heat loss ................................................................................................................... 354 Heat loss from other sources ................................................................................. 355 Regulation of body temperature ................................................................................. 355 Normal variations in body temperature .................................................................... 356 Measurement of body temperature ............................................................................ 356 Contraindications for using the various sites to measure body temperature .... 357 Management of common clinical problems related to temperature regulation ... 358 Pyrexia...................................................................................................................... 358 Rigors ....................................................................................................................... 359 Malignant hyperpyrexia/hyperthermia ................................................................ 360 Heat stroke ............................................................................................................... 361 Hypothermia ............................................................................................................ 362 Conclusion ..................................................................................................................... 363 Suggested activities for students ................................................................................ 364

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Chapter 20: Nutrition ............................................................................. 365 Introduction ................................................................................................................... 368 Nutrients ........................................................................................................................ 368 Macronutrients .............................................................................................................. 368 Carbohydrates ......................................................................................................... 368 Proteins .................................................................................................................... 371 Lipids (fats and oils) ............................................................................................... 374 Micronutrients ............................................................................................................... 376 Vitamins ................................................................................................................... 376 Minerals ................................................................................................................... 381 Water/fluid ..................................................................................................................... 385 Sources of water/fluid ............................................................................................ 386 Factors affecting nutrients in food ............................................................................. 386 Genetics and growing conditions ......................................................................... 386 Bioavailability of nutrients .................................................................................... 386 Handling and processing of food ......................................................................... 387 Nutrition in relation to health .................................................................................... 387 Recommended dietary allowance (RDA) .............................................................. 387 South African Food-Based Dietary Guidelines ................................................... 387 Nutrition through the life cycle .................................................................................. 390 Nutrition during pregnancy and lactation .......................................................... 390 Infant nutrition ....................................................................................................... 392 Nutrition during childhood ................................................................................... 394 Nutrition during adolescence ................................................................................ 395 Nutrition in adulthood ........................................................................................... 395 Nutrition in the elderly .......................................................................................... 396 Nutritional guidelines for people living with hiv/aids and/or TB ...................... 397 Nutrition interventions .......................................................................................... 397 Nutritional guidelines for people with non-communicable diseases ..................... 399 Assessment of nutritional status ................................................................................. 400 Anthropometric measurements ............................................................................. 400 Interpreting the measurements ............................................................................. 401 Biochemical or laboratory analysis ...................................................................... 403 Clinical examination .............................................................................................. 403 Diet history .............................................................................................................. 404 Preparing a nutritional care plan ............................................................................... 404 Implementing a nutritional care plan ........................................................................ 405 Diets used in hospital/care facilities ..................................................................... 405

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Ensuring adequate food intake ............................................................................. 407 Enteral nutrition ..................................................................................................... 408 Parenteral nutrition ................................................................................................ 409 Special community nutritional services .............................................................. 409 Evaluation of nutritional outcomes ........................................................................... 410 Common nutrition-related problems .......................................................................... 410 Conclusion ..................................................................................................................... 417 Suggested activities for students ................................................................................ 417

Chapter 21: Assessing and maintaining fluid, electrolyte and acid–base balance .............................................. 419 Introduction ................................................................................................................... 421 Maintenance of fluid balance ..................................................................................... 421 Electrolyte balance ................................................................................................. 422 Acid–base balance .................................................................................................. 424 Nursing assessment of fluid, electrolyte and acid–base balance ........................... 425 The patient’s history................................................................................................ 425 Physical assessment ................................................................................................ 425 Diagnostic tests ....................................................................................................... 427 Management of common clinical problems related to fluid, electrolyte and acid–base balance ................................................................................................. 427 Fluid volume deficit ............................................................................................... 427 Fluid volume excess ............................................................................................... 429 Electrolyte imbalances ........................................................................................... 431 Hypernatremia: Sodium excess ............................................................................. 431 Hyponatremia: Sodium deficit .............................................................................. 433 Hyperkalaemia: Potassium excess ........................................................................ 434 Hypokalaemia: Potassium deficit .......................................................................... 435 Hypercalcaemia: Calcium excess .......................................................................... 437 Hypocalcaemia: Calcium deficit ........................................................................... 438 Disturbances of acid–base balance ....................................................................... 441 Respiratory acidosis ................................................................................................ 443 Metabolic acidosis .................................................................................................. 444 Respiratory alkalosis .............................................................................................. 445 Metabolic alkalosis ................................................................................................. 446 Intravenous therapy ............................................................................................... 449 Conclusion ..................................................................................................................... 450 Suggested activities for students ................................................................................ 451

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Chapter 22: Mobility and exercise need ............................... 452 Introduction ................................................................................................................... 454 Mobility and exercise need ......................................................................................... 455 Activities of daily living ........................................................................................ 455 Factors affecting mobility ........................................................................................... 456 Growth and development ...................................................................................... 456 Nutrition ................................................................................................................... 456 Environmental factors ............................................................................................ 456 Prescribed limitations ............................................................................................. 457 Nursing assessment of mobility .................................................................................. 457 Physical assessment ................................................................................................ 457 Nursing history ....................................................................................................... 458 Meeting the mobility needs of the patient................................................................. 458 Active exercise ........................................................................................................ 458 Passive exercise ....................................................................................................... 458 Relaxation ................................................................................................................ 462 Bedrest ............................................................................................................................ 462 Positions in bed ....................................................................................................... 463 Common clinical problems related to maintenance of mobility ............................ 466 Complications of bedrest ....................................................................................... 466 Prevention and management of the complications of bedrest ......................... 471 Moving patients ............................................................................................................ 477 Guidelines for moving patients ............................................................................. 477 Turning a patient in bed ........................................................................................ 477 Logrolling a patient ................................................................................................ 477 Role of the physiotherapist and the nurse ................................................................ 478 Conclusion ..................................................................................................................... 478 Suggested activities for students ................................................................................ 479

Chapter 23: Elimination needs ....................................................... 480 Introduction ................................................................................................................... 483 Normal physiological function of elimination ......................................................... 483 Urine ......................................................................................................................... 483 Faeces ....................................................................................................................... 485 Vomiting .................................................................................................................. 487 Nursing assessment of elimination ............................................................................ 488 Urine ......................................................................................................................... 488 Faeces ....................................................................................................................... 494

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Vomiting .................................................................................................................. 499 Common clinical problems related to the maintenance of elimination................. 500 Facilitating micturition and regular defecation .................................................. 500 Prevention of constipation .................................................................................... 502 Nursing intervention during vomiting ............................................................... 505 Urethral catheter care ............................................................................................. 506 Functional bladder problems ................................................................................. 509 Essential health promotion and health education .................................................... 511 Conclusion ..................................................................................................................... 512 Suggested activities for students ................................................................................ 512

Chapter 24: Comfort, rest and sleep need ......................... 514 Introduction ................................................................................................................... 515 Sleep: its functions and importance .......................................................................... 515 How much sleep is necessary? .............................................................................. 516 Circadian rhythm .................................................................................................... 516 Sleep cycle ............................................................................................................... 516 Physiological changes during sleep ..................................................................... 517 Factors that influence sleep and rest ................................................................... 519 Common sleep disorders ........................................................................................ 521 Nursing interventions to promote sleep .............................................................. 521 Pain: its functions and importance ............................................................................ 522 Specific objectives .................................................................................................. 522 Physiology of pain .................................................................................................. 522 Types of pain ........................................................................................................... 523 Response of the body to pain ................................................................................ 525 Nursing assessment of comfort, rest and sleep ......................................................... 526 Causes of discomfort............................................................................................... 526 Assessment of discomfort ...................................................................................... 526 Facilitating comfort ................................................................................................ 527 Assessment of pain ................................................................................................. 528 Clinical signs and symptoms of pain ................................................................... 528 Pain rating scales .................................................................................................... 529 Patients who cannot communicate ...................................................................... 530 Relief of pain ........................................................................................................... 530 General measures to relieve pain and promote comfort ................................... 531 Behavioural techniques .......................................................................................... 532

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Drug therapy ........................................................................................................... 533 Radiation therapy ................................................................................................... 535 Other supportive therapies ..................................................................................... 535 Facilitating rest and sleep ...................................................................................... 536 Conclusion ..................................................................................................................... 536 Suggested activities for students ................................................................................ 537

Chapter 25: Skin integrity need ................................................... 538 Introduction ................................................................................................................... 540 The anatomy of the skin .............................................................................................. 540 Appendages of the skin .......................................................................................... 540 The functions of the skin ............................................................................................. 541 Effects of loss of skin integrity ............................................................................. 542 Nursing assessment of the skin and skin integrity .................................................. 542 History taking related to the skin and skin integrity ......................................... 543 Physical assessment of the skin and skin integrity ............................................ 545 Assessment of the hair and nails .......................................................................... 546 Assessment of pressure areas ................................................................................ 547 Management of common clinical skin problems ..................................................... 547 Principles of skin care ............................................................................................ 547 Common skin problems ......................................................................................... 550 Essential health promotion and health education .................................................... 552 Commonly used skin care products ..................................................................... 552 General health education ....................................................................................... 552 Health education for specific skin problems ....................................................... 553 Wounds and wound healing ....................................................................................... 556 Classification of wounds ........................................................................................ 556 Types of wound ....................................................................................................... 556 Wound healing ........................................................................................................ 557 The wound healing process ................................................................................... 558 Wound assessment .................................................................................................. 559 Principles of wound care and promotion of wound healing ............................ 561 Wound complications ............................................................................................. 563 Conclusion ..................................................................................................................... 565 Suggested activities for students ................................................................................ 565

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Chapter 26: Hygiene and grooming needs ......................... 566 Introduction ................................................................................................................... 568 The meaning of hygiene .............................................................................................. 568 Nursing assessment of hygiene and grooming ......................................................... 569 Skin ........................................................................................................................... 570 Hands and nails ...................................................................................................... 570 Hair ........................................................................................................................... 570 Mouth and teeth ...................................................................................................... 571 The eyes ................................................................................................................... 571 The genitalia ............................................................................................................ 572 Common clinical problems .......................................................................................... 572 Maintenance of hygiene and grooming in patients unable to help themselves ............................................................................................................... 572 Hygiene of the eyes, ears and nose ...................................................................... 575 Oral hygiene and mouth care ................................................................................ 576 Genital hygiene ....................................................................................................... 578 The maintenance of hygiene in neonates and infants ....................................... 578 Conclusion ..................................................................................................................... 580 Suggested activities for students ................................................................................ 580

Chapter 27: Sensation, perception and cognition ...... 581 Introduction ................................................................................................................... 584 The functions of the central nervous system ............................................................ 584 Interpretation of sensory information ................................................................. 584 Control of motor function ..................................................................................... 585 Higher cognitive functions .................................................................................... 585 Nursing assessment of functions related to sensation, perception and cognition ........................................................................................................................ 585 Assessment of sensory function ........................................................................... 586 Common clinical problems .......................................................................................... 590 A visually impaired patient ................................................................................... 590 A patient with a hearing impairment .................................................................. 591 A ‘confused’ or delirious patient .......................................................................... 592 An unconscious patient ......................................................................................... 595 Conclusion ..................................................................................................................... 597 Suggested activities for students ................................................................................ 598

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Contents

Chapter 28: Peri-operative nursing care .............................. 599 Introduction ................................................................................................................... 601 Surgery ........................................................................................................................... 601 Indications for surgery ........................................................................................... 602 Types of surgery ...................................................................................................... 602 The effects of surgery on the patient ................................................................... 603 Factors that affect the patient’s ability to cope with surgery ........................... 608 Nursing assessment of the special needs of the patient undergoing surgery ....... 610 Nursing management of the patient undergoing surgery ....................................... 611 Pre-operative nursing ............................................................................................. 611 Preparation of the patient for surgery in the ward ............................................ 613 Intra-operative care ................................................................................................ 615 Preparation of the operating room ....................................................................... 616 Nursing care of the patient in the recovery room .............................................. 618 Return to the ward and handover ........................................................................ 618 Post-operative nursing ................................................................................................. 618 Aims of post-operative care .................................................................................. 618 Preparation of the environment ........................................................................... 619 Receiving the patient from theatre ....................................................................... 619 Nursing care during the later post-operative period .......................................... 619 Preparation for discharge and health education ................................................ 620 Post-operative complications ...................................................................................... 621 Early post-operative phase .................................................................................... 621 Late post-operative phase ...................................................................................... 623 Complications due to anaesthesia .............................................................................. 624 Ventilator complications ........................................................................................ 624 Pain ........................................................................................................................... 624 Nausea and vomiting ............................................................................................. 624 Cardiovascular complications ............................................................................... 625 Shivering .................................................................................................................. 625 Essential health promotion and health education .................................................... 625 Health education aspects ....................................................................................... 625 Conclusion...................................................................................................................... 625 Suggested activities for students ................................................................................ 626

References .......................................................................................................... 627 Index ........................................................................................................................ 633

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Preface Over the years since the publication of the first edition of this text, the nursing profession continues to see many changes, particularly in respect of legislation and policy such as the developments more recently with the National Health Insurance (NHI) and Primary Healthcare Re-engineering. Developments around the care and management of HIV and AIDS and the impact of this disease on our communities continues to be profound and far-reaching. In a nurse-driven healthcare service such as in South Africa, the nurse is expected to keep abreast of all the many changes and incorporate them into his or her practice. The editors believe that these developments needed to be incorporated into the texts used during basic training so that nurses become familiar with concepts such as home-based and community-based care and outreach teams as they apply in the NHI right from the outset. All the chapters have been updated to comply with the requirements of the new prescribed nursing education and training programmes. New items have been included such as essential health literacy which refers to the information people require to successfully maintain their wellness and health and to actively participate in decision making and management of their health. Features of the book such as specific outcomes for each chapter, key concepts and terminology, important ethical and medico-legal aspects as well as suggested activities for students have been retained as these make the text reader-friendly. Two key principles are embraced to form a golden thread throughout the book. Inclusion of the Bill of Rights in the South African Constitution emphasises the importance of human rights. Therefore human rights, which refer to the moral principles and norms observed in society, inform all chapters highlighting that rights also include obligations. In the same vein, the rich cultural diversity of South Africa requires practitioners who can provide culturally competent care. This relates to nurses who understand and are sensitive to the cultural habits, practices and life styles of different ethnic, racial or religious groups, which should inform the clinical care they provide to their patients. The authors hope that students, nursing educators and all other users of this book will find this revision useful. The editorial team: N. Geyer S. Mogotlane A. Young H. Boshoff M. Chauke M. Matlakala J. Mokoena P. Naicker M. Randa

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Acknowledgements In bringing together this third edition of Juta’s Manual of Nursing, Volume 1 we have once again had help from numerous people and our gratitude goes out to all who were involved. Particular thanks go to every nurse educator who took the time to give input to improve the content. Thanks once again to the late Norah Veale (former Principal of the B. G. Alexander Nursing College) for her inspiration and support in the development of the ideas and the framework for the first edition, which have been further developed for the second and third editions. Once again, our gratitude and appreciation go to the team at Juta for their neverfailing support and professionalism. To all our valued contributors, the editors say a big thank you for all the hard work and sacrifice. The authors and publisher gratefully acknowledge permission to reproduce copyright material in this book. Every effort has been made to trace copyright holders, but if any copyright infringements have been made, the publisher would be grateful for information that would enable any omissions or errors to be corrected in subsequent impressions. Figure 16.1 The Johari Window. Source: Luft, J. 1984. Group Processes. Silver Spring: NTL Institute for Applied Behavioural Science. Table 27.3 The Glasgow Coma Scale. Source: Teasdale, G. & Jennett, B. 1974. ‘Assessment of coma and impaired consciousness: A practical Scale’. Lancet 13 (a): 81–4.

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About the authors Editors Nelouise Geyer B Cur (UP) (RN, RM, Psych & Community Health); M Cur (UP) (Education & Intensive Care Nursing); Dipl Nursing Education; Dipl Nursing Management; PhD (UKZN) Chief executive officer of the Nursing Education Association (NEA) Sophie Mataniele Mogotlane RN; RM; RCHN; Dipl Nursing Education; Dipl Paediatric Nursing; BA Cur (University of South Africa); MA Cur (Unisa); PhD (Natal) Emeritus professor and a research fellow in the College of Human Sciences at the University of South Africa Anne Margaret Young RN; RM; Dipl ICU; Dipl Nursing Education; BA Cur (University of South Africa) Formerly academic head, Post-Basic Department, Chris Hani Baragwanath Nursing College

Contributors Hananja Boshoff RD (SU); Junior lecturer for Rural Clinical School, Division of Human Nutrition, Stellenbosch University Motshedisi Eunice Chauke RN; RM; RCHN; RT; Dipl Nursing Education; Dipl in Intensive Nursing Science; BA Cur (Unisa); MA Health Studies (Specialisation: Critical Care Nursing, Cardiothoracic Nursing) (Unisa) Lecturer, Department of Health Sciences, University of South Africa Mokgadi Christina Matlakala RN; RM; RNA; RPN; RCHN; RT; BA Cur (Unisa); M Cur (Critical Care Nursing) (Medunsa); Dipl Med Surg Nursing (Critical Care Nursing, Cardiology and Cardiothoracic Surgery) Lecturer, Department of Health Sciences, University of South Africa Joyce Desia Mokoena RN; RM; RT; RCHN; Dipl Nursing Education (Medunsa); Dipl Community Nursing (Medunsa); BA Cur (Hons) (Nursing Education) (Unisa); MA Cur (Unisa); PhD (UL) Senior lecturer, University of Limpopo, Medunsa campus Peggy Kannagi Naicker RN; B SocSc (Nursing); Dipl ICU; Dipl Education; MA Health Sc Quality assurance manager – Life College of Learning Moreoagae Bertha Randa RN; RM; N Ed; N Admin; RCH; Dip ICU; Dip OHN; BA Cur (Pretoria); MPH (Medunsa) Lecturer, Medunsa xxiv

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section

1

Contents

Fundamental nursing science

Health services and nursing care remain at the cutting edge of science with new innovations to improve care continuously evolving. There is no doubt that, irrespective of where one chooses to take one’s career, it must be based on a solid foundation labelled as the fundamentals in nursing. This foundation considers the importance of the fundamental needs of human beings and the basic competencies as prerequisites to develop clinical reasoning skills so that nurses provide safe, quality care to the patients and communities they serve. In order to start to build this essential foundation, Part 1 of this book introduces students to nursing with some of the important building blocks necessary for becoming professionals who are competent and caring practitioners. Chapter 1 is an introduction, and deals with the origins of nursing, and its meaning and purpose, as well as the role of the nurse in the provision of quality care. Chapters 2 and 3 provide students with the professional, legal and ethical framework within which the nurse and midwife practise in this country. Good nursing care is dependent on good information and therefore information management has been addressed in Chapter 4. In chapters 5, 6, 7 and 8 information is provided on the bio-psychological and spiritual needs of patients, how to practise nursing in a culturally diverse society and how a community assessment should be done to identify the needs of communities. Chapters 12 and 13 provide guidelines on maintaining safety and infection control in all areas where patient care is delivered to minimise medico-legal hazards. The importance of establishing therapeutic relationships with patients cannot be overemphasised, hence Chapter 14 introduces students to the art of communication and teaching. The first part of this book rounds off the introduction to nursing with chapters 15 and 16, which cover how to care for nurses as workers and individuals, as well as some of the skills and attributes that are required to develop a satisfying career in nursing.

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chapter

1

Introducing nursing

Learning objectives On completion of this chapter, the student should be able to do the following: • Analyse nursing, its origins through its history, its meaning and purpose. • Apply the basic principles of nursing care in nursing practice. • Explain the concepts health, ill health and disease as they apply in the various stages of life. • Explain the role of a nurse in maintaining health and providing care in ill health and disease in the various stages of life. • Explain the goals and philosophy of the healthcare delivery system in South Africa. • Explain the theories of nursing that are appropriate to a system that is focused on the provision of primary healthcare to meet the basic needs of the community.

Introduction Competent and effective nursing care is based on an awareness of the overall meaning and purpose of nursing. Through a process of understanding and internalising the theories and ideas that underlie and support the activities of nursing, nurses will develop a personal philosophy of nursing. In order to understand the importance of nursing in healthcare and healthcare delivery, the concepts of health and ill health and the role of nurses in relation to these states of being must be understood. These concepts also need to be understood in relation to the various stages of the life cycle. Nurses must also develop an understanding of the goals and philosophy of the healthcare delivery system in South Africa, since this is the basis for their nursing activities. There is also a need for orientation in holistic theories of nursing that are appropriate to a system that is focused on the provision of primary healthcare to meet the basic needs of the community. Nursing is made up of many different activities that flow from the concept of caring. The scope of nursing ranges from the provision of the most basic care to the execution of complex activities requiring critical thinking, reflection, decision making and technological skill. As an intellectual activity based on moral foundations, successful nursing requires scientific knowledge combined with the ability to apply that knowledge in the patient-care situation. It is an interpersonal process that focuses on the needs of patients at the promotive, preventive, curative or rehabilitative level.

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Key concepts and terminology Casualties: People who are injured, for example in motor vehicle accidents, violence or falls. Civilisation: To develop people by providing them with information that changes their behaviour in a positive manner. Crusades: Christian expeditions. Embalming: Preservation of dead bodies. Infirmary: A place where sick people are accommodated. Trepanning: Making a surgical hole in the skull in order to relieve pressure by removing fluid or blood.

Key ethical considerations • The obligation on nurses to be constantly mindful of the primary mission and purpose of nursing in all healthcare situations. • The obligation on nurses to give holistic care in all healthcare situations. • The monitoring of changes in the healthcare environment and adapting nursing theories and nursing practice accordingly. • The prediction of future changes and trends, and their impact on nursing. • The development of nursing theories and constructs that maintain the purpose of nursing while accommodating change. Failure to do so may place patients and the profession at risk. • The awareness that conflict may arise when different sectors of the health services use different methods and approaches to care.

Key legal considerations • Healthcare policies and the healthcare delivery systems are based on such policies as determined by the government of the day in consultation with experts and healthcare professionals who are called upon to advise the government. Such policies are then implemented by means of appropriate legislation. The National Health Act 61 of 2003 provides a framework for a single health system in South Africa. • The scope of practice of registered nurses and registered midwives is broad. It allows nurses to provide an effective service to their patients, within their capabilities. This broadly based scope of practice is intended to facilitate flexibility and adaptability in providing nursing care (see Chapter 2).

Historical perspectives The activity of nursing is as old as humankind. Nursing began with the activities required to care for the sick and helpless individuals in the community. As caregivers 4

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passed their knowledge on to younger caregivers, a body of nursing knowledge began to develop. The various images of nursing over the years are described below.

The images of nursing The folk image

The folk image of nursing has come down to us from what is known of ancient cultures and civilisations. Nursing generally seems to have been a female role, an extension of mothering, and was often associated with a mother, a family member or a community member who possessed special caring skills. The word ‘nurse’ is derived from the same root as the word ‘mother’, meaning to nourish and nurture. The folk image embraces such concepts as care, concern, organisation, service, support, love and accessibility, and remains deeply embedded in the human consciousness. The idea of a nurse as someone who embodies care, concern and compassion is not simply an ancient folk image but that which has passed into the ethical and professional codes of nursing. Developments in medical care, being more dramatic, were better documented, and are thus easier to trace. In Egypt, physicians successfully performed operations such as trepanning, fractured bones were splinted, embalming was practised and many diseases were described including tuberculosis and arteriosclerosis. Medical schools and hospitals were built. Medical service was directed by laws and codes: in Persia, ceremonial rules relating to birth and death were contained in the Zoroastrian scripture, the Avesta; the Hebrews practised healthcare according to the Mosaic Code; Babylonian practice was subject to Hammurabi’s Code of Laws by which unskilled practitioners were outlawed. Records also exist of medical development in Babylon and among Africans, American Indians, Asians, Romans and Greeks. The religious image

The teachings of Christ emphasised the concepts of love and service to humankind. As a result, nursing care was extended beyond the home and family to include widows, orphans, the sick and the desolate poor. Individuals and religious groups established monasteries, hospitals and home-visiting services. Well-known spiritual leaders of the early Christian period who are associated with nursing include Phoebe (mentioned by St Paul), Fabiola, Marcella and Olympias, who used their wealth to found hospitals. Monasticism fostered the development of a culture of learning and high moral values, which viewed the care of the sick, and especially the care of the sick poor, as being an important activity. Every monastery had an infirmary, some of which grew and developed to become large hospitals, many of which are still in existence today. Benedictine monasteries were especially well known for their care of the sick, and some famous monastic nurses, such as St Brigid, St Scholastica and St Radegonde date from this period. During the crusades, Christian military nursing orders marched with the armies and cared for the injured. Throughout the Middle Ages and into the Reformation, almost all hospitals in Europe were run by religious orders. The Reformation brought about changes to the religious orders and many of them made provision for lay members, who entered the order for a defined period of time. Protestant orders were also instituted. The Society of the Protestant Sisters of Charity was established in 1840 by Elizabeth Fry, who had done much to alleviate the conditions in English prisons. Indeed, Fry’s efforts had so impressed a Lutheran in Germany – Pastor Friedrich Liedner 5

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– that he became a prison pastor, and in 1836 he and his wife Frederika established the Kaiserwerth’s Institute for the training of deaconesses. This institution helped to lay the foundations of modern nursing, as many of the deaconesses who trained there were sent out to start up nurse training in other countries. In the Roman Catholic Church, the Brothers Hospitallers of St John, an order for males only, founded hospitals in Europe and started different services, such as ambulances, residences for homeless men and services for chronically sick and aged persons. In the Muslim countries, a similar service was given to the community in the name of God (Allah). Charity and compassion for the sick and poor are important core values in Islam. Rofiada Islamiah, the wife of the Prophet Mohammed, is acknowledged as the mother of nursing in the Arabian Peninsula. The name Rofiada means carer of the sick and injured. The religious motif remains an important strand in the norms and values of modern nursing, and the idea of disinterested and ethical service to humankind has passed into the ethical and professional codes of nursing. Less fortunately perhaps, the idea stemming from monastic times of a nurse as someone who nurses purely out of love for humankind has lingered in the public consciousness and is sometimes used as an argument for condoning poor salaries and unsatisfactory conditions of service in nursing. The military image

The military image stems from the need to have persons on hand to care for the wounded during and after a battle. In earliest times, the women of the tribe or community followed the men and waited at the edge of the battlefield to care for the wounded. The development of the state and of organised government brought armies into being. In early times armies had permanent camp followers, who were usually sex workers but who were also able to care for the wounded. Battlefield medical care also stimulated developments in surgical techniques and in wound care that required a more specialised level of care. The founder of modern nursing, Florence Nightingale, rose to fame as a result of her work in organising and improving the care of the wounded at Scutari during the Crimean war in the 19th century. As warfare and weapons became more sophisticated and more destructive, the need grew for specially trained and skilled nurses to care for casualties. Nowadays military nursing is a well established branch of the profession and has seen the development of many valuable techniques in rescue and resuscitation and in the management of large numbers of casualties. The image of military nursing is also based on concepts of military discipline, obeying orders and an authoritarian and hierarchical structure. At their best, these concepts facilitate an ordered and disciplined approach to patient care. At their worst, an oppressive culture that stifles creative thought is developed, in which unquestioning obedience and the blind following of orders are encouraged. The military image lingers on in the uniforms, distinguishing devices and administrative structures of nursing. The ‘Dark Ages’ of nursing

From approximately 1500 to 1860, the image of the nurse progressively regressed to that of a servant. The period was marked by vast economic, social, intellectual and political changes. Nursing changed radically. Although the religious orders continued to provide selfless care for the sick, the standards of care in secular nursing dropped steadily, 6

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until, in the mid-19th century, Dickens epitomised nurses in the loud, crude, dirty and slovenly image of the character of Sairey Gamp in his novel Martin Chuzzlewit. The principles of selfless service and charity were eroded by changes flowing from the reformation, and the outbreak of pestilence, war, famine and civil disorder. Hospitals became places of suffering and death. Servants, patients, vagrants, pardoned criminals and poverty-stricken homeless people were recruited to provide hospital care. The very low wages paid to these people and the appalling working conditions may explain the extremely low standards of care at the time. The image of Sairey Gamp serves as a cautionary tale for today’s nurse. If nursing standards and levels of expertise are not upheld and maintained, nursing will return to these ‘Dark Ages’. Modern nursing

Although all of the previous images made important contributions to the development of nursing, and their influence can still be identified, it is generally agreed that the founder of modern nursing is Florence Nightingale. Florence Nightingale, an icon of modern nursing, recognised the importance of educating nurses in order to attain optimum care for the sick. Persevering against family and social opposition, she initiated research on sanitation and health. In 1853, after her period of study with the Fliedners at Kaiserswerth, she was appointed to reorganise hospital care and nursing at the Establishment for Gentlewomen. Thereafter, she became superintendent of King’s College Hospital. When Britain entered the Crimean war, Florence was recruited to supervise the military hospitals in Turkey. Her efforts culminated in the reform of British military health services which, unfortunately, left her in poor health. Her work, however, continued and she wrote extensively on hospital sanitation and military healthcare. In 1860 she established the Nightingale School and introduced a pattern for nursing education to be followed throughout England. The course of theoretical and practical training that she developed set educational standards to meet human needs. Her programme for district nurses prepared them for more independent work than that of their peers in the hospital. Florence Nightingale was the first proponent of nursing as a profession.

Nursing in South Africa before 1900 The first hospital in South Africa was started at the Cape of Good Hope in 1652. At the time, the Dutch (Dutch East India Company), who had established a halfway station at the Cape to provide fresh food and water for ships going round the Cape on the voyage between Holland and India, started a temporary tent hospital to take care of sick sailors. A permanent hospital was eventually completed in 1656. Nursing conditions were difficult. Diseases such as typhoid and scurvy were rife. Convalescent soldiers, who gave whatever care they were willing and able to, provided care to others. Improvement came gradually, with the first Binnenmoeder (matron) and Siekenvader (male nurse/ supervisor), who were appointed around 1700, to supervise the slaves who acted as bedside attendants, and to ensure the general cleanliness of the hospital and patients. Subsequently the Dutch East India Company employed a few Sworn Midwives from Holland who, in addition to their midwifery practice, started the training and examination of local women, who were in turn placed into midwifery practice. Generally, however, wives, mothers, relatives and neighbours cared for the sick at home.

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Historical documents describe the care as being of a high quality. From 1807 onwards, more hospitals were built to meet the growing demands, more patients were treated and services were extended. The earliest hospitals in the Eastern Cape were founded in Port Elizabeth, King William’s Town, Grahamstown and Queenstown. The numbers of doctors and nurses also increased gradually. The first members of a religious order to arrive in South Africa were the Roman Catholic Nuns of the Assumption Order. In 1874, two Nightingale nurses, as well as the first of the Anglican Sisterhoods, the Community of St Michael and All Angels, arrived from England. It was members of this Order who laid the foundations of professional training for nurses in South Africa. The discovery of diamonds in the Kimberley area made the introduction of hospitals necessary in order to care for the thousands of fortune seekers who poured in from all over the world to the diamond diggings. Male army orderlies were appointed to nurse the sick in these hospitals. Alternatively, friends and neighbours cared for sick prospectors in the time-honoured fashion. This influx of miners, contract workers, traders and other hangers-on, coupled with the generally squalid conditions in the mining encampments, encouraged the spread of disease. Dysentery, typhoid and malaria were rampant. The building of more hospitals became imperative and nurses were sorely needed. Assistance was sought from the Anglican Order of St Michael and All Angels in Bloemfontein. Following negotiations with Bishop Webb, members of this Order, including Sister Henrietta Stockdale, were assigned to the Carnarvon Hospital. Sister Henrietta Stockdale became a major figure in South African nursing. She had studied nursing but did not complete her training. Her good classical education, however, brought her an appointment as a teacher. She was enthusiastic, resourceful and willing to serve where needed. On her arrival at the Carnarvon Hospital in 1877, she started a training course for the nurses working with the Anglican sisters. Many of those nurses who qualified under Sister Henrietta moved to hospitals farther afield – Barberton, Pretoria, Queenstown and Cape Town – where they continued with the training of nurses. This laid the foundations of professional nursing in South Africa. Sister Mary Hirst Watkins, who qualified in nursing and midwifery under Sister Henrietta, was the founder of modern midwifery training in South Africa. The introduction of state registration under the Medical and Pharmacy Act 34 of 1891, through the effort and drive of Sister Henrietta, was her ultimate contribution to the development of professional nursing in South Africa. Although most mission hospitals are now state hospitals, the various mission societies, missionary orders and other missionary groups made a significant contribution to the development of hospitals and healthcare in South Africa. Hospitals like Jane Furse Memorial (Sekukuniland), the Holy Cross (Flagstaff ), the Charles Johnson Memorial (Nqutu), the All Saints (Engcobo) and St Lucy’s (Tsolo) are examples of the Anglican contribution. Roman Catholic Orders initially concentrated on the establishment of hospitals, but also introduced nurse training in Zimbabwe. Well-known Roman Catholic contributors included the Orders of the Assumption and the Blessed Sacrament as well as the Dominican Order and the Order of the Holy Family of Bordeaux, who first staffed the Johannesburg General Hospital. The Glen Grey (near Queenstown) and the Umlamli (Sterkspruit) hospitals are but two of the numerous hospitals and training schools established by the Roman Catholics. The contributions of a variety of other church groups to health services and nursing education include the Elim and Masana hospitals (Swiss Presbyterian), the Church of Scotland and the Donald 8

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Fraser hospitals (Church of Scotland), Ceza Hospital (Lutheran), George Stegmann, Groothoek, Philadelphia, Rietvlei, Tshilidzini and HC Boshoff hospitals (Dutch Reformed Mission) and the Jubilee, Moroka and Shongwe Mission hospitals (Swedish mission).

Nursing in South Africa in the 20th century The early years of the century, which opened with the Anglo-Boer War in progress, were characterised by major health problems: war injuries; concentration camps; killer diseases like measles, pneumonia, dysentery and typhoid; and a shortage of medical and nursing personnel. The shortage was aggravated by the increased need for nurses due to the outbreak of World War I (1914) and the accompanying difficulties that prevented the preparation of sufficient numbers of registered nurses. These included insufficient training facilities and the fact that the training of South African women of all races was lagging behind. At the same time, however, training opportunities were increasing and courses in general nursing, midwifery, psychiatry (mental health) and community health (district and school health nursing) were in progress or being introduced. Other historic developments in these years included the following: • The first organisation for nurses, the South African Trained Nurses’ Association, which was formed in 1914 • The promulgation of the first Nursing Act (No 45 of 1944) • The introduction of the first nursing journal, The South African Nursing Record, in 1913 • An apprenticeship type of training of nurses, where greater emphasis was on the staffing needs of the healthcare facilities than on the learning needs of students • Nurses were educated and trained on the job. Initially, all training institutions were attached to hospitals. In time, some of the smaller institutions merged to form colleges at larger hospitals, and often these were academic hospitals • The introduction of the first two diploma courses in nursing education at the University of Witwatersrand and the University of Cape Town in 1935 to enable nurses to train as tutors • The importance of military nursing, which was officially recognised by the Defence Act 13 of 1912. Many nurses today hold top positions in the South African National Defence Force. Training of black nurses Formal training for black nurses started at Lovedale in 1902. Cecilia Makiwane was the first to qualify in this institution, in 1907. Georgina Judson was the first coloured nurse to register (1917) in Cape Town. These two women, however, were not the first women of colour to make a contribution to nursing. From the earliest days at the Cape, black, coloured and Malay women had provided nursing care, both in the home and in the healthcare institutions of the time, but this contribution was not recognised and they were viewed as servants. Some of the early Sworn Midwives at the Cape were freed Malay and coloured slaves. A career in nursing was not considered appropriate for Indian women, but some Indian males became registered nurses or orderlies. Highlights in nursing development after 1950 Numerous changes have come about in nursing since 1950. The scope of this chapter does not permit a detailed description, but a brief overview of some of the more outstanding events is given: 9

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• Political influences leading to the establishment of independent states and homelands in South Africa resulted in the formation of independent nursing councils, as well as nursing associations for the Transkei, Bophuthatswana, Venda and Ciskei. Since the present government came into power (1994) the different councils have been merged into one national nursing council, the South African Nursing Council (SANC). The separate nursing associations, as well as the South African Nursing Association, have also been merged into one organisation and transformed into the current Democratic Nursing Organisation of South Africa (DENOSA). Both SANC and DENOSA are fully representative of all races in the country. • Legislative changes after 1994 include changes in health legislation to ensure equitable and accessible healthcare especially for children, pregnant women and the aged; a new Nursing Act and a democratic constitution that upholds human rights. • In 1953 nursing schools became the only recognised institutions to provide theoretical education to registered student and enrolled pupil nurses. The first degree course leading to registration as a nurse commenced at the University of Pretoria in 1956. Today fifteen universities offer degree courses leading to basic registration as well as post-graduate degree courses. From 1986 onward, nursing schools became colleges of nursing. These were required to present basic nursing education in association with universities. A four-year comprehensive course leading to registration as a nurse (general, psychiatry, community) and midwife was introduced in 1986. • A BCur degree for black nurses commenced at the Medical University of Southern Africa (Medunsa) in 1980, and a Department of Nursing Science was established at the University of Zululand in 1981. • The University of South Africa (UNISA) introduced graduate and post-graduate degrees for registered nurses in 1976. Large numbers of nurses have used this opportunity to qualify in community nursing, nursing education and nursing administration. The most recent developments include the following: • The movement to rationalise the existing number of nursing colleges • The entrance of private hospital groups into nurse training • The establishment of private nursing colleges • The system of accreditation for all institutions offering nurse training – all such institutions are now required to be accredited by the South African Nursing Council • Registration and accreditation of nursing programmes with the South African Qualifications Authority (SAQA) • A system of compulsory professional development (CPD) whereby every registered nurse will be required to provide official proof of upgrading and ongoing professional education in order to renew her or his registration with SANC • Community service of one year for newly qualified nurses.

The meaning of nursing What nursing is, and what it is not, has been debated since the time of Florence Nightingale. A single brief definition has not been standardised. Nursing continually changes to meet the needs and circumstances of particular groups in particular countries at particular times. Nursing is sensitive to prevailing politics and legislation, national 10

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health problems, and economic and educational restraints, and has progressed from nurturing the sick and needy to catering for all health needs of all persons. Its four broad aims are to promote health, prevent ill health, restore health and promote coping (rehabilitating) after radical health changes. The word ‘nurse’ was originally derived from the Latin nutrix or nutricis, which meant someone who tended or nourished (nutrio) the young, sick, or infirm (Home Study Dictionary). Today, any existing definition of nursing is much wider than simply nurturing, although nurturing and caring remain at the core of nursing. Florence Nightingale described nursing as ‘the act of utilising the environment of the patient to assist him in his recovery’ (Nightingale 1860). In a position paper on education (1965) the american Nurses’ Association (ANA) explained nursing as an independent profession and said: ‘Nursing is a helping profession and, as such, provides services which contribute to the health and wellbeing of people.’ Virginia Henderson, one of the first 20th century American nursing scholars, defined nursing as ‘primarily assisting the individual (sick or well) in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge’. Within the self-help concept, it is likewise the unique contribution of nursing to help the individual to be independent of such assistance as soon as possible. The understanding of nursing expanded rapidly as more organisations and authors expressed views on its nature and the functions and roles of nurses. The central focus in all remained the person who requires holistic care, taking into consideration his or her physical, emotional, spiritual and social needs. In most of the modern literature, authors and organisations describe nursing as a profession, a discipline and a science. Recognition of nursing as a profession is derived from its compliance with the criteria for a profession (Chapter 2). As a science, nursing is based on a distinct body of knowledge that can be applied in the clinical situation and which is continually being expanded by ongoing research. The South African Nursing Council defines nursing science as follows: ... A human clinical health science that constitutes the body of knowledge for the practice of persons, registered or enrolled under the Nursing Act as nurses or midwives. Within the parameters of nursing philosophy and ethics it is concerned with the development of knowledge for the nursing diagnosis, treatment and personalised health care of persons exposed to, suffering, or recovering from physical or mental ill health. It encompasses the knowledge of preventive, promotive, curative and rehabilitative health care for individuals, families, groups and communities and covers man’s lifespan from before birth. As a discipline, nursing has the following characteristics: • It is a system comprising a specific, unique body of knowledge. • It uses existing and new knowledge to solve problems and to meet human needs in its own particular and dynamic field. • It requires study and practice separate from other disciplines.

Selected theories of nursing A theory is characterised by: • Clear, logical, sensible description of concepts specific to nursing 11

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• Well-explained relationships between concepts • Congruence (agreement, comparability) with the basic assumptions used in its development • Its usefulness and the applicability of its concepts in the clinical situation • Its value in nursing education, research and practice. The value of a nursing theory is as follows: • It provides rational, knowledgeable reasons for actions based on organised written descriptions of the reality of nursing. • It provides a knowledge base for acting and responding appropriately in nursing care situations. • It provides a base for discussion. • It provides resolution on current nursing issues. • It promotes problem-solving skills of the knowledgeable nurse practitioner to provide organised, considered and purposeful nursing action. • It prepares the nurse to question assumptions and values, thus leading to other/ further definitions of nursing and an increased knowledge base. The need to have one universal theory, rather than multiple theories of nursing, is continuously debated. A single universal model would enhance the development of nursing as a profession, provide a common framework for communication and research, and contribute to a better understanding of the nurse’s holistic healthcare role in hospital as well as in non-hospital settings. However, there are several theories that are used in nursing. The advantage in this is that they allow nursing phenomena to be examined from many angles and to be viewed from different perspectives. For example, in psychology, it is difficult, if not impossible, to find one satisfactory unified theory that expresses the complexity of human behaviour. Psychologists believe that many different theories are needed to help them understand human behaviour. Nursing is likewise an activity that is intensely human, dealing with human needs and behaviour in health and in illness. This makes nursing a complex activity, which cannot be fully explained by a single theory.

Components common to nursing theories All nurse theorists thus far have identified four major components common to nursing practice wherever it occurs. These are the following: • Person • Environment • Health • Nursing. The person, whether described as patient, client, health consumer, human being, individual or other, is the most important reason for the existence of nursing practice. Individual theorists describe the four concepts and the relationship between them according to their own perspectives, beliefs and experiences.

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An overview of selected nursing theories The theory of Florence Nightingale as abstracted from her writings, Virginia Henderson’s theory based on her definition of nursing, Dorothea Orem’s self-care deficit theory and Imogene King’s goal-attainment theory all reflect their individual beliefs about nursing. An overview of each will highlight the theorist’s description or definition of the four major components or elements of nursing in accordance with personal philosophy, scientific knowledge and clinical experience. Florence Nightingale (1860)

Florence Nightingale’s views are centred on the influence of the environment and the processes of repair at the patients’ disposal. An analysis of her writings shows that she considered the person to be an individual who desires health and who deals with disease through vital reparative processes yet does not strive to adapt the environment or to influence the nurse. Health means being well and having the power to function fully, using environmental factors to maintain health. Disease means that nature initiates a reparative process due to some want of attention. Nursing is an act of providing for optimal environmental conditions to promote and maintain the individual’s own reparative processes. The concept of environment in this theory embraces the physical environmental aspects, which include warmth, diet, cleanliness, ventilation, light and the absence of noise. Nightingale’s beliefs about the influences of environmental factors in health promotion and maintenance and in caring for the sick remain as important today as when Nightingale first opposed the poor sanitation, working conditions and the low quality of nurses and nursing in the hospitals of her day. Virginia Henderson

When Virginia Henderson first formulated a definition of nursing in 1955, it served to establish nursing as a discipline in its own right. Her extensive definition refers to an individual’s needs, in relation to health and the role the nurse plays to meet the needs. Henderson’s views are briefly summarised under the four components of nursing practice: Person. A person is an independent, whole and complete being with 14 basic needs, which include the following: • To breathe normally • To eat and drink adequately • To eliminate • To move and maintain posture • To sleep and rest • To dress and undress • To maintain body temperature • To keep clean and well groomed • To avoid danger and injury to self and to others • To communicate to express emotion, needs, fears and opinions • To worship according to the particular person’s faith • To work and experience a sense of accomplishment 13

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• To relax through recreation and play • To promote development and health. Health. A quality of life achieved by an individual through independent (done alone) or interdependent (done with others) performance of the 14 components of nursing care in order to work effectively and to reach the highest potential. To attain health, an individual must have the necessary strength, will or knowledge. Nursing. A unique function of a nurse is to assist individuals, sick or well, in performing those activities contributing to health, its recovery (or peaceful death) which individual would perform unaided if they had the necessary strength, will or knowledge. This includes doing the activities in such a way that it may help individuals gain independence as soon as possible. Environment. The environment is considered as the sum total of internal and/or external influences/conditions affecting the life and development of an organism. Dorothea Orem

Dorothea Orem first published her self-care deficit theory in 1971. According to this theory, individuals are naturally capable of providing care to self as well as to their dependants. By initiating and performing these behaviours, they strive to maintain life, health and wellbeing. The ability to accomplish self-care is an adult activity termed ‘self-care agency’. Infants, the aged, disabled and ill individuals require assistance with their self-care activities. These are said to have a self-care deficit. Self-care requisites (requirements) differ according to stages of development and health states where different levels of assistance may be needed. Self-care requirements may be the following: • Universal: Common to all people, these are activities necessary for daily living. They include air, water, food, elimination, social interaction and safety. • Developmental: Requirements arising from developmental processes occurring throughout the lifecycle. • Health-deviation requisites: Needs that arise from defects and deviations from the normal structure and integrity of the individual and which affect his or her ability to perform self-care. The self-care deficit theory shows that nursing benefits the individual (the self-care agency), who, for health reasons, cannot adequately provide self-care, for example feeding an adult patient who may be unable to feed himself because of illness.

Nursing alert! The self-care deficit concept allows nurses to make a specific nursing diagnosis by identifying the patient’s self-care deficits.

The nursing systems theory complements the self-care deficit theory. Nursing systems develop when nurses prescribe, design and provide nursing to compensate for people’s self-care deficits. Orem identifies three types of nursing system: (a) wholly 14

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compensatory, when a nurse provides for every activity required for daily living as in the care for an unconscious patient; (b) partially compensatory, when a nurse assists an individual to perform a function as in early ambulation, where the nurse supports the individual to walk; and (c) supportive-educative systems, when an individual can and is capable of self-care but is unable to carry this out due to lack of information on how to go about performing the self-care activity, as in a mother with a premature infant. The composition and level of nursing care needed differ from system to system. According to Orem, persons are humans with bio-psychosocial and interpersonal components who meet their self-care needs through learned behaviour. Health, when positive, symbolises wellness. The value placed on the term ‘health’ differs between individuals and between cultures. Health is considered to be behaviour of high value, and illness one of low value. Nursing is a service that focuses on persons who are unable to meet their self-care needs. Nursing is a deliberate action aimed at creating such conditions as human beings desire for themselves and in their environment. Nursing education and experience enable nurses to give direct assistance to individuals. Environment, although not dealt with in great detail, is associated with the individual, as well as the values and expectations of the particular society. As such, it is an integrated and interactive system. The nursing community has widely accepted Orem’s theory and applies it in health institutions and community services. Imogene King’s theory

Imogene King’s theory was initially published in 1971. It is a theory of goal attainment, based on a conceptual framework of three open systems (personal, interpersonal and social) in dynamic interaction. Specific concepts are identified and interact in each system as follows: • Personal system: This system relates to the individual (eg the nurse and the patient/ client). Applicable concepts are perception, body image, growth and development, self, space and time. • Interpersonal system: This system relates to groups (eg peer groups). Applicable concepts are interaction, communication, transaction, role and stress. • Social system: This system relates to communities (eg Soshanguve, Langa, Richmond) and applicable concepts are organisation, authority, power, status and decision making. • Communication and interaction (act, react, interact): When purposeful, this system results in transaction that may lead to goal attainment. According to King, the person as a human being is an open system that is rational and purposeful. A person perceives and controls an action within a time frame. Health is a purposeful, adaptive response to the changing (dynamic) life experience of a human who utilises the available resources optimally to attain his or her potential in daily life, by continually adapting to the stresses of the external and internal environment. Nursing is a process of human interaction whereby a nurse and a patient/client, perceiving each other and the situation, set goals together by communicating and agreeing on how to achieve these. Environment is not specifically defined. King’s theory contributes to nursing knowledge regarding interactions between the nurse/

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client/group. It emphasises the importance for individuals to participate in mutual goal setting and goal attainment.

Theories and the nursing process The two aims of nursing theory development are as follows: • To increase the body of nursing knowledge • To facilitate communication on nursing by using a common terminology of defined words and concepts. Nursing theory must be made real by applying its conceptual model in clinical practice. Nursing is therefore practised by using a systematic process known as the nursing process. The nursing process consists of assessment, nursing diagnosis, planning, implementation, evaluation and record keeping, which are integral to the whole process. Assessment usually relates to the component of the person/client. Virginia Henderson explains the person as an individual with 14 basic needs. In assessment, information about the extent to which each need is met or unmet will be collected. A nursing diagnosis will be based on what was discovered in the assessment. Planning must also be done in relation to the diagnosis. Orem’s theory, for instance, requires the design of care to foster activities that promote self-care. Implementation requires scientific knowledge, which directs the nurse on the care to give and how to do it based on the nursing diagnosis. Evaluation, according to Henderson’s model, demands continuous reassessment of the extent to which a patient’s needs have been satisfied, new needs that may have arisen and how the patient adjusts or responds to the care given. Evaluation enables nurses to judge the effectiveness of the nursing process.

Models for nursing the individual, family or community Nursing theory and nursing practice are interlinked. Nursing theory cannot exist without cognisance of what happens in the nursing field. Nursing practice benefits from implementing a theoretical model that gives logic, communicability and direction in the application of the nursing process. In the nursing process, nurses’ total knowledge is used to attain quality nursing care.

Stages of the life cycle and the role of nurses Nursing care is needed during all stages of life to promote the quality of a person’s health, to prevent ill health, to care for him or her during periods of ill health and to optimise wellbeing within the boundaries set by ill health. The cycle of life is completed in different stages of growth and development. Growth is a physical phenomenon characterised by an increase in height, weight, body size and other physical attributes during the first 20 years of life. Growth slows down after adolescence and is minimal in adulthood. Development refers to an increase in complexity to function, for example sitting, crawling, walking and running. Development continues for much longer than physical growth. Genetics and environmental factors influence growth and development. Maturation is a sequence of physical changes influenced by genetics but independent of environment. Environmental factors, for example climate, education and nutrition do, however, impact on maturation. Psychosocial development relates to personality development 16

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and includes the development of feelings, temperament, self-esteem, interpersonal skill, adaptability and other related characteristics. Growth and development were widely studied during the 20th century, resulting in a variety of theories. The psychoanalytic theory of Freud, and the developmental theory of Eriksson – although not included in this chapter – are but two theories, which can, in spite of certain limitations, promote a nurse’s understanding of the stages of human development. Each individual has particular needs during each stage of growth and development. Knowing the needs that are pertinent to each developmental stage facilitates the assessment of needs and how these can be met. Table 1.1  Stages of growth and development and the associated special needs Stage of growth/

Special needs to be met

development

Parental: conception to birth

Need for knowledge and support to create an environment conducive to foetal development

Neonatal: birth to 28 days

Need for bonding (parenting skills), safety, communication, security to build trust, inclusion and cohesion within family

Infancy: 1 month to 1 year

Physical, psychosocial, environmental control and relationship (infant–parent–family) needs. Need for continuous close contact with parent/guardian, nutrition, hygiene and skin care, sleep and rest, skills development, play, infection prevention and treatment

Toddler: 1–3 years

Need for playing, sleep and rest, talking, emotional security, nutrition, safety, psychosocial development, hygiene, dental care, infection control, toilet training

Pre-school: 3–6 years

Need for basic skill learning (balancing, drawing, throwing, cutting, exercise, counting, imitating), play activity, health maintenance, safety, dental hygiene, emotional, moral, affective, cognitive development (self-esteem), sleep and rest

School age: 6–12 years

Need for sexual awareness, social skills, self-identity, peer and child–adult relationships, perceptual growth, increased interest in and preparation for adult roles  Need for physical, cognitive, social, mental and moral development, acceptance, play, communication, mobility, love and friendship, accident and infection prevention

Adolescence: 12–20 years (early, middle, late)

Need for sexual identity and education, becoming less involved in family and more in peers, school and workplace commitment, building a personal philosophy and developing a moral/value system, lasting and quality relationships with adults (parents). Need for esteem, value development, coping with stress, appearance, cognitive, sexual, spiritual and communication relationships, health education and maintenance needs (drugs, ➙ accidents, food, nutrition), social responsibility

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Stage of growth/

Special needs to be met

development

Young adulthood: 20–40 years

Equilibrium in social activities, establishing a career, increased selfidentity, achieving intimacy with another person, health education (diet, exercise, rest), attention to incidental health, sexual and pregnancy needs, adjustment

Middle adulthood: 40–65 years

Need for empowerment in community matters; surgical, medical and chronic health needs; sexual needs: menopause and postmenopause; psychological and spiritual needs: empty-nest syndrome, changed relationship patterns, loss and grief; need for lifestyle changes; ill-health recognition, health maintenance and rehabilitation needs

Older adulthood: 65+ years

Retirement, physical decline and sometimes mental/cognitive needs; age-related health problems, accidents, loss and grief, chronic ill health, hygiene maintenance needs, isolation, interaction, safety, nutrition, self-esteem needs, rest and sleep

The health–ill-health continuum and the role of nurses The health status of patients influences the way nurses relate to them and the use of the nursing process. Exploration of the meaning of health, illness and disease promotes understanding of what nurses do and what nursing means. Every individual perceives health differently. The way the World Health Organization (WHO) defines health does not necessarily agree with every individual’s personal view of health. The World Health Organization (WHO) definition of health: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

An individual’s perception of health is shaped in various ways and may change according to that individual’s stage of life, level of development, health and ill-health experiences, level of physical and psychosocial interaction, and cultural affiliation. Since 1940, the concept of ‘health’ has been widely discussed and debated. The establishment of nursing as a science made it imperative to define health because it is the reason for the existence of nursing. Virginia Henderson in 1955 first defined health as the following: • An ability to meet the 14 basic needs which are integral to health • A quality of life that allows people to work most effectively to attain the highest possible satisfaction in life • A quality of life which is basic to human functioning and which requires independence and interdependence • A state that may be achieved or maintained if a person has the necessary strength, will or knowledge.

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According to Martha Rogers’s publications between 1970 and 1989, positive health symbolises wellness. She sees health as a value word defined by the individual or defined within the individual’s understanding of the concepts of health and illness in relation to high or low value. During the development (1972–1989) of the Health Systems Model, Betty Neumann attended to both health and illness in her definition of health. She described health as a value between wellness and illness. Wellness is a condition in which all parts and subparts of an individual are in harmony with the whole system, while illness indicates a lack of harmony. Health is visualised as a shifting point on a line (continuum) between wellness and illness. Optimal wellness results when all the needs of a person are being met. Unmet needs cause a reduction in wellness. The individual’s state of wellness– illness may alter at any moment in time. As early as 1984, McCann-Flynn and Heffron published their health–illness continuum model to illustrate the holistic health model (see Figure 1.1). death

critically ill

very ill

ill/well

fairly ill

well

peak of health

Health–illness continuum

Figure 1.1  Health–illness continuum Source: Adapted from Mc Cann-Flynn & Heffron (1984).

Various authors developed other health models in an attempt to clarify the relationships between health and the factors that impact on health. These include the agent–host– environment triangle (Leavell & Clark 1965) (see Figure 1.2) and the health-belief model (Rosenstock 1974). Environment

Agent

Host

Figure 1.2  Agent–host–environment triangle

The agent–host–environment model The agent–host–environment model, applicable to all situations, is especially valuable in community healthcare and epidemiology. It identifies risk factors in the interaction between host, environment and agent (see Figure 1.2). Awareness of such risk factors facilitates prevention of illness, health promotion and maintenance. Health depends on a balance between the three factors, which may influence health negatively when not in harmony. Illness may occur in the following instances: • The agent – mechanical, psychosocial, biological, chemical or physical – is present or absent. 19

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• The external environment of the host increases the risk of illness by reducing the chances of remaining well. Lack of proper housing, safe water and employment, the presence of intensive noise, smoke and chemical contamination are examples of external environments that increase the risk of illness. • The host is the human being or organism that may be harbouring the agent or providing a conducive environment for the agent.

The health-belief model The health-belief model describes the health behaviour of people in relation to what they believe about themselves and about health, and in relation to the decision-making process in seeking healthcare services. According to this model, it is believed that individuals will take action to prevent, screen for or control an ill-health condition or situation if they regard themselves as being susceptible to a condition that may have serious consequences, or that will affect their lifestyles, as well as believing that a course of action on their part would benefit them by reducing either their susceptibility to the condition or its severity, and that the barriers to taking action, in terms of costs, are outweighed by the benefits of action. This model includes three components that people may perceive: • Their susceptibility to disease • The seriousness of a disease • The value of action. The perceived susceptibility to a disease or illness relates to understanding the process of contracting a disease, and ranges between being afraid of becoming ill to complete denial that certain behaviour may cause illness. Perceived susceptibility depends on people’s belief as to whether they will or will not become ill. The perceived seriousness of a disease concerns the disease itself and the seriousness of its impact on the lifestyle of an individual. These include the possible social consequences impacting on employment, family and social relations. Other consequences of illness include pain, disability and death. The perceived value of action lies in people’s beliefs about how effective preventive measures will be in preventing illness. These beliefs are influenced by the conviction that the disease can be modified or prevented by implementing the recommended behaviour and the belief that it will be cheaper and less unpleasant to take the recommended action.

Illness and disease Illness is one side of the health–illness continuum (see Figure 1.1). Nurse theorists describe illness as contrary or opposite to health: Imogene King refers to illness as interference in the lifecycle; Betty Neumann explains it as a lack of harmony among the parts and subparts of the individual’s system. Illness is not synonymous with disease. A person may feel ill without showing signs and symptoms of the disease, or may feel very well although having a malignant tumour (a disease) of which he or she is not yet aware. Illness is a personal subjective feeling, while disease causes a regression in physical capacity and life expectancy. Disease refers to functional changes of the body that may affect the scope of a person’s capabilities, or a specific ability, or which may even shorten a person’s life. Traditionally, disease used to be seen as affecting particular organs or parts of the 20

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body only, and medical treatment was focused on these parts. The concept of ‘holism’, however, has been gaining acceptance and today most health professionals view the individual as a whole and acknowledge the multiple-causation theory of health problems. The primary healthcare approach of South Africa supports the holistic view of a person and of illness. Holistic healthcare takes the whole person within her or his environment into account. Modifying factors

Likelihood

Demographic variables (age, sex, race, ethnicity)

Perceived benefits of preventive action

Sociopsychological variables (personality, social status, peer & reference group pressure)

Minus

Individual perceptions

Perceived susceptibility to disease Perceived seriousness of disease

Structural variables (knowledge of disease, prior contact with disease) Perceived threat of disease

Perceived barriers to action

Likelihood of taking recommended preventive health action

Cues to take action Mass-media campaigns Advice from others Reminders from doctor or dentist Illness of family member or friend Newspaper or magazine article

Figure 1.3  Health–belief model Source: Becker (1974)

A multiple causation theory considers all factors impinging on health as contributing to illness, although these factors (eg unemployment, lack of housing and safe water, or smoking) are not diseases in themselves. The modern concept of illness must take all into account: the total person within his or her family (considering, for example, biologic and genetic factors) and within his or her community (considering, for example, social problems, culture and environment).

Social factors that influence disease In addition to individual health beliefs and health behaviour, the health of an individual may be influenced by certain social factors, such as the following: • Socio-economic level – the higher an individual’s socio-economic level, the better the individual’s health. High socio-economic level is also correlated with more active health promotion behaviour, such as a regular physical examination or 21

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regular visits to the dentist. People of lower socio-economic levels generally have poorer health and are more inclined to accept ill health as a way of life. • Education is an important social factor in health. Generally, the better educated an individual is, the healthier he or she is likely to be. The better the education, the more likely the individual is to adopt healthy behaviours and a healthy lifestyle. Education is probably a more important determinant of health than socio-economic level, as the effects of education can cancel out the effects of socio-economic disadvantages. • Economic circumstances, usually related to socio-economic level, are a vitally important factor in the health of an individual as well as that of a community. Generally, the more affluent an individual or community, the better the level of health. Economic factors are important in health for very practical reasons. For example, poor communities: –– do not have health and other facilities such as water, electricity and sanitation –– do not have spare money to pay for visits to doctors or to clinics –– are often overcrowded, thus promoting the spread of disease –– are frequently undernourished, which also contributes to poor health and the development of disease. • Culture plays an important role in health. Culture determines the way in which an individual views disease, and how that individual responds when ill.

The sick role When people feel ill, their actions differ from when they feel well. Their actions constitute ‘illness behaviour’ and they assume a ‘sick role’. Sick role is a status that is awarded to a person who displays illness behaviour and is thus perceived as sick by significant others. Illness behaviour may consist of one or more of the following behaviours: • Noticing symptoms that indicate illness, such as pain, rash, cough, fever, and many more • Seeking confirmation of such illness from significant others who may give advice on what to do to relieve the signs and symptoms of illness or where to go to get help (lay referrals) or may award a sick role status allowing the person to relinquish his or her responsibilities, including giving up his or her normal activities even to the extent of doing nothing • Buying over-the-counter medicine, visiting a doctor or, in some cases, a traditional healer (diagnosis and prescription help to make the illness legitimate) • Accepting a dependent or sick role status means conforming to other people’s opinions, requiring assistance to meet basic needs and needing emotional support, acceptance, approval, physical contact and protection • Entering a health institution and being in need of effective carer–patient relationships, illness information and individual care plan, while being aware of the family and caregiver expectations that she or he will recover and be able once again to fulfil her or his normal roles

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• Finally recovering, regaining independence, accepting responsibility once more, fulfilling normal roles, sometimes being healthier than before, and implementing the lifestyle changes motivated by effective health education. There are no time limits or specific order to sick role behaviour. It varies from person to person, and situation to situation. A nurse’s task is to attend to each behaviour of every patient in a consistent manner. The nurse should do the following: • Demonstrate acceptance of the person. • Meet the needs for care in an order of priority. • Give physical and emotional care, and health education to promote the patient’s return to a healthy state.

Approaches to healthcare delivery systems in South Africa Modern healthcare is a complex business involving many health professionals ranging from doctors and nurses to the allied health professions such as physiotherapists, nutritionists or occupational therapists. Approaches to healthcare vary, and only the most important concepts are dealt with here. The approach to healthcare that is being implemented has an important influence on the way in which nurses practise their profession. • Preventive healthcare is care that seeks to prevent the development of ill health by modifying the factors that contribute to disease, whether these factors are environmental, social or behavioural. • Promotive healthcare seeks to raise the level of health of individuals and communities through education, empowerment and development, both of individuals and communities. • Curative healthcare provides diagnosis, care and treatment for the individual who has become ill. • Rehabilitative healthcare seeks to return the sick individual to optimum health, and to return the individual to as normal a life as is possible. • Primary healthcare (PHC) involves the delivery of essential, affordable, accessible and acceptable healthcare to a community. Primary healthcare involves the provision of essential basic care at the individual’s point of entry into the healthcare system. It focuses on health promotion, disease prevention and management of community diseases, as well as a measure of rehabilitation. The PHC approach is a priority of the National Health System in South Africa and it lies at the base of an integrated district health system. • Comprehensive healthcare involves an approach that combines all of the above approaches into a system that provides a variety of healthcare facilities to meet all of the healthcare needs of the population. It is provided in public and private healthcare facilities in South Africa. It is important to note that no single approach to healthcare will meet all of the healthcare needs of the population. For healthcare to be comprehensive and to meet all needs, all of the above types of healthcare approach should be applied.

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Healthcare services in South Africa The national health system The post-apartheid government that came to power in 1994 in South Africa was faced with many challenges. One of these was to transform a highly fragmented health system, in terms of design and legislation, into a comprehensive, equitable, non-racial and integrated national health system (NHS) that would, in collaboration with the other social systems, redress social and economic injustices, eradicate poverty, reduce waste and duplication/fragmentation of services, increase efficiency and promote greater control by communities and individuals over all aspects of their lives. The NHS is a single governmental structure that co-ordinates all aspects of healthcare delivery (public and private) at national, provincial, district and local levels. The aim is to decentralise management of healthcare delivery services to provinces, districts and institutions in order to increase efficiency, local innovation, empowerment and accountability in the communities served. The system puts emphasis on health – not only on medical care – and on equity, accessibility and affordability through the primary healthcare approach with health promotion, prevention, curative and rehabilitation inherent in its operation. Within this introduction, the responsibilities of the various authorities are as follows: At national level

The national health authority is responsible for the following: • Providing leadership • Formulating national policies • Building capacity in provinces and municipalities including trade unions, NGOs involved with health issues, private providers and other stakeholders • Ensuring equity • Providing certain services that would be most cost-effective at national level • Developing information systems • Monitoring progress including co-ordination of training systems • Providing regulation of the public and private health sectors • Supporting provinces and municipalities in order to remain accessible • Effecting national and international liaison and collaboration. At provincial level

The provincial health authority is responsible for the following: • Develop provincial policies and guidelines based on the national norms, policies and guidelines. • Plan, monitor and evaluate health services in the province based on the national norms, policies and guidelines. • Provide hospital and academic health services, which include specialised rehabilitation support centres. • Approve, within national guidelines, standards and norms, the building and expansion of public and private hospitals and clinics. • Supply human resource management and development within the province. • Plan and control the functions of the referral system.

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• Provide and co-ordinate medical emergency services, including ambulance services. • Provide technical and logistical support to the health districts, as well as co-ordinating the district health authority’s (DHA) work in the province. • Provide district-level services where the DHA is unable to do so. • Plan and manage a provincial health information system. • Ensure quality control of health services and facilities. • Effect interprovincial and intersectoral co-ordination and collaboration. • Co-ordinate the budgets of the district health services. • Provide specific provincial programmes, such as TB prevention and treatment. • Provide non-personal health services. • Provide and maintain equipment, vehicles and healthcare facilities. • Consult on health matters at community level. • Provide occupational health services. • Undertake research. • Plan, co-ordinate, monitor and evaluate provincial services. • Ensure that functions delegated at national level are carried out. At district level

The district health authority (DHA) is responsible for ensuring that all health services in the district are provided within the norms, policies and guidelines agreed upon at national and provincial levels. These include the following: • Promotion of primary healthcare, planning, monitoring and evaluation of services • Management and co-ordination of health-promotion activities • Collaboration with governmental sectors and NGOs • Engagement of communities in their healthcare matters • Provision of PHC and other relevant services within the community, in clinics, community health centres, district hospitals and other facilities • Provision of primary environmental health services, essential medico-legal services and services to persons arrested and charged. Administrative, financial and support services, as well as planning and human resources, are provided through negotiated agreements between the province, its districts and municipalities.

The public healthcare system The public or government sector, in the name of the Department/Ministry of National Health, is the biggest employer of nurses and owns the majority of nurse-training hospitals. In South Africa, the employers of nurses are mainly the Department of Health at national level, nine provincial health departments in the nine provinces and numerous municipalities that have, in collaboration with the provinces, established the district health system. The private sector healthcare system Private sector healthcare facilities consist of private nursing homes, hospitals and clinics. These may also provide for their own training of nurses. In addition, some physicians, registered nurses and allied health personnel, such as physiotherapists and 25

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occupational therapists, run independent private practices. A private sector service functions as a business with a profit motive, but it is subject to the Health Act and must be registered. In the private facilities, consumers meet the costs incurred for services from their own pockets, or these are partly paid for by medical aid or insurance schemes. Medical aid schemes are regulated by the Medical Schemes Act 131 of 1998. Private health organisations may enter into contractual arrangements with the government to provide specific services to the public sector health consumers. In such cases, payment for services is incurred by government with the consumer paying very little, if anything at all.

Non-governmental organisations Non-governmental organisations (NGOs) are mainly privately funded by donors. The National Department of Health may, however, commission an NGO to perform services on its behalf. In such a case, the department will sign a contract with the donor(s) concerned and take the responsibility for expenditure in the service required. NGOs employ nurses of all categories and contribute to nurse training.

Conclusion Nursing originated as an answer to suffering caused by ill health and disease. It has developed to a science and art that, through care and concern, can enhance people’s wellbeing at any point on the health continuum. Understanding the nurse’s role, its scope and how it differs from the roles of other health professionals requires an understanding of conceptual models and theories of nursing. Nurses provide care during all stages of life to individuals and to families. Effective care considers people’s needs at different stages of the lifecycle. Understanding health, ill health, disease and health models enables nurses to provide holistic care which considers individual needs and attends in a similar fashion to a variety of behaviours displayed by individual patients. The healthcare system of a particular country and its preferred approach to healthcare influence the education and placement of nurses, as well as the scope of nursing practice.

Suggested activities for students (NB! Students are advised to read broadly so as to be able to engage in the discussions stemming from the content of the chapter.) Activity 1.1 After reading the section on the historical perspectives of nursing, explain, in not more than three typed pages, the origins of nursing and of nursing education in South Africa.

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Activity 1.2 Students should form groups to discuss the following concepts: nursing, health, ill health, and how they apply to nursing in the various stages of life. Activity 1.3 • Under which sector does the hospital associated with your college belong? • What type of hospital is this in terms of tertiary, secondary and primary levels? And what are its functions? • What are the capabilities of your district in terms of healthcare delivery?

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chapter

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Practising the profession of nursing within the South African professional legal framework

Learning objectives On completion of this chapter, the student should be able to do the following: • Apply the legal framework within which he or she practises with insight and understanding. • Identify the criteria for recognition of nursing as a profession, and apply these criteria to nursing in the South African context. • Identify the essential features of professional conduct and how these apply to the day-to-day practice principles. • Demonstrate comprehension of the regulatory control of the nursing profession in South Africa and the ability to apply legislation to own practice. • Demonstrate understanding of the role of professional associations or organisations and unions for nurses and the nursing profession.

Key concepts and terminology Advocacy: The process of providing support, referral, liaison, representing and protecting the interest of individuals and families who may or may not be aware of the need or are unable to co-ordinate or arrange healthcare for themselves. Civil law (private law): Deals with relationships between individuals, including contractual relationships, and a breach of duty or a wrong or delict (an act by which one person infringes on the rights of another) leading to liability for damages. The most relevant wrong or delict leading to legal action against nurses is negligence. Civil law is concerned with legal action of one individual against another to redress some wrong or to settle a dispute. The burden of proving someone wrong lies with the person who brings the legal action (the plaintiff), and this person has to prove on a ‘balance of probabilities’ that a wrong or delict has been committed. The outcome is usually an order by the court that one side pay the other side an amount of money; that a person ➙ perform an obligation; or that a person is restrained from doing certain things.

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Constitution: Usually the supreme law of the country. It incorporates a ‘due process’ clause (applicable to acts in consequence of which a person may be deprived of his or her property or life), and an ‘equal protection’ clause (ensuring a person or group the same legal protection as is granted to other persons or classes of persons in similar circumstances). Criminal law: Deals with disputes between an individual and society as a whole, meaning that societal norms would have been disregarded and, if found guilty, the individual is deemed to have committed a criminal act. The state as the representative of its people prosecutes a person for committing an offence and is called the prosecutor. An important presumption in our legal system is that a person is innocent until proven guilty. The police or another body will do the investigation, and the prosecution has the burden of proving all the elements of the offence with which the accused is charged. The accused does not have to say anything if he or she does not wish to do so. It must be established ‘beyond reasonable doubt’ that the accused person committed the offence before a sentence is handed down. A person who has been found guilty of a criminal offence has a criminal record for the rest of his or her life, and this can be removed only through presidential pardoning. Criminal liability can arise from the following: • Murder, for example through active euthanasia when a nurse intentionally and unlawfully causes the death of patient. • Culpable homicide, where the death of a patient is brought about unintentionally, for example through the administration of incorrect medication, or an incident that could have been prevented if ‘due care’ was taken and the nurse was reasonably vigilant. • Other incidents that may lead to criminal prosecution are, for example, the assault referred to earlier, as well as crimen injuria where a person’s dignity was wounded by divulging information on his or her health status to, for example, the media. • There must be proof that the nurse acted with malicious intent, and therefore consciously chose to do it. • Sometimes an incident may involve both civil and criminal law proceedings. When a motorist runs down a cyclist, the police will investigate a charge of reckless driving which may be followed by criminal proceedings in court. However, the cyclist may also bring civil proceedings against the driver to recover monetary compensation for any damages suffered. The difference here relates to the consequences that follow. Criminal law is concerned with the punishment of offenders, while civil law is concerned primarily with compensation. Indemnity: Usually means a form of insurance that will provide the nurse with legal advice and representation should the nurse be involved in legal action related to his or her professional activities. Law: Formally prescribed and legally binding rules made by the authorities to regulate social conduct so that individuals need not fear for the safety of their person or property. Liability: The legal responsibility to account for, or answer for, one’s actions or omissions. Financial compensation may be claimed in the case of wrongful actions. Liability can be transferred to a third party, for example buying indemnity insurance or vehicle insurance that will make provision for financial compensation in the event that a person requires it. ➙

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Negligence: Consists of the failure of a nurse to act in accordance with prevalent professional standards or failure to foresee possibilities and consequences that a nurse, with the necessary skill and training to act professionally, should see. A nurse would therefore be acting negligently if he or she failed to exercise the care a reasonable nurse would exercise in the same circumstances. The question to be answered here is whether the reasonable nurse could have foreseen and would have prevented the damage or injury. • A breach of duty or a wrong or a delict may be intentional, as in: –– defamation, when calling patients or colleagues offensive names –– assault or battery, when slapping a child or taking blood for HIV testing without the patient’s informed consent –– invasion of privacy, when disclosing information about patients to the wrong person –– fraud, when recording nursing actions that were not in fact done –– malpractice and negligence, such as euthanasia where intentional action is taken by the nurse to hasten the death of the patient. A breach of duty or delict may also be unintentional, as in unintentional negligence, when a patient is injured during a procedure performed by the nurse in which the nurse failed to exercise the care a reasonable nurse would exercise in the same circumstances. • In all of these instances, there was an act that was wrongful where the wrongdoer was at fault (intentionally or unintentionally) and there was a causal connection between the act and the ultimate loss suffered. Proclamation: While an Act of parliament is always signed by the president of the country before it is published for general information to the public, it only becomes operational once the Act is proclaimed, which means that the president publishes an official declaration in the Government Gazette to state on which date the Act in its totality, or which sections of the Act, can be implemented. Statutes: Laws that define and regulate certain aspects of life. The Nursing Act 33 of 2005, for instance, defines and regulates nursing. Various other Acts have implications for nursing, such as the Choice on Termination of Pregnancy Act 92 of 1996, the Medicines and Related Substances Act 101 of 1965, and the Compensation for Occupational Injuries and Diseases Act 130 of 1993. Supportive care: All services which enhance the other elements of care essential to individualised care, including health education, advocacy and counselling. Touting: Conduct which draws attention, either verbally or by means of the printed or electronic media, to one’s offers, guarantees or material benefits that do not fall within the category of professional services or items, but are linked to the rendering of a professional service or are designed to entice the public to the professional practice. Vicarious liability: Responsibility for the conduct of another person. An employer, having entered into a contractual relationship with an employee, for example a nurse, to deliver a service on his behalf, takes responsibility for the conduct of that employee. The health service is thus responsible for the conduct of the nurse and may be sued for malpractice on the part of the nurse. The employer may in turn sue the nurse for financial compensation, and therefore every nurse should have personal malpractice insurance.

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Chapter 2 Practising the profession of nursing within the South African professional legal framework

Prerequisite knowledge No specific prerequisite knowledge is required other than the awareness that society is governed by rules and laws that determine order, for example the rules of using our roads. This also includes the knowledge that society has norms and ethical standards by which individuals are judged, as well as expectations in relation to behaviour.

Medico-legal considerations In South Africa, no one may practise nursing unless they are registered with the South African Nursing Council (SANC). Nurses must know what their legal-ethical framework consists of. The key legal considerations include the following: • Nurses are the gatekeepers for the protection of the human rights and safety of their patients. • Ignorance of the law is no excuse for doing the wrong thing, and nurses therefore have an obligation to ensure that they remain informed. • In a court of law, if the nurse did not record what was done for the patient, it is regarded as never having been done.

Key ethical considerations • The nurse has an obligation to take due care in all activities relating to patient care, and to avoid negligent actions. • The nurse has a duty to maintain respect for the patient and to avoid any action that could harm or otherwise disadvantage the patient. • The nurse has an obligation to maintain confidentiality regarding the patient’s health status or any other information relating to the patient, and to protect the name, person and property of the patient. • The nurse has a duty to maintain effective and proper working relationships with other health service professionals. • The nurse has an obligation to use the full spectrum of his or her nursing skills to meet the needs of the patient, family and community, and to ensure continued competency through lifelong learning. • The nurse is expected to ensure that his or her off-duty activities and behaviour are a credit to the profession. • The nurse is expected to maintain acceptable standards of professional conduct and practice, and to bring instances of improper or unprofessional conduct to the attention of the appropriate authorities. • The nurse is expected to be honest in his or her recording of nursing actions and the response of the patient to these actions. • The nurse is expected to diligently fulfil all professional and contractual obligations in respect of the patient, the employer and other health service professionals.

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Essential health literacy Patients have a constitutional right to be fully informed about the nursing profession and the services the profession provides so that they can make an informed decision on the treatment that they receive and be respected for their choices. Nurses have an obligation to confirm that patients understand the health information provided in order to assist them to make appropriate healthcare decisions.

Nursing implications As practitioners, and especially as students, we cannot know everything. If you do not know what to say or do, remember to ask for assistance.

Introduction Through understanding and internalising the core values of nursing, the nurse will be able to practise nursing safely, competently and accountably. Compliance with the legal requirements of the profession is an obligation on every nurse in South Africa. While the Constitution of the Republic of South Africa (RSA) Act 108 of 1996 determines that everyone has the right to choose their profession, it also determines that some professions, such as the health professions, are regulated by additional laws related to their specific profession. Nurses are fully accountable for their professional judgement and actions, and will therefore require some knowledge of basic legal concepts, a detailed discussion of which is beyond the scope of this book. The choice of nursing as a career therefore implies that the nurse has voluntarily accepted the legal obligations attached to the profession, and it is further implied that all registered nurses are aware of these legal requirements. The conscientious maintenance of the basic concepts as outlined in the legislation will enhance the image and status of the nursing profession in South Africa, as well as ensure that a competent and ethical service is rendered to the public at large.

The professional status of nursing Nursing has a proud history of self-regulation as a profession. South Africa was the first country in the world to register its nurses in 1891 – first with the Medical Council, and from 1944 with the South African Nursing Association. A profession is a career requiring specialist knowledge and skills within a recognised system of learning authenticated by professional members. A profession functions autonomously and continuously strives to extend its body of knowledge whilst maintaining and regulating standards, therefore a professional is a specialist in a particular occupation or speciality. A profession has a culture of its own; it has definite norms and values, and acts as a unifying force to bring together individuals from many diverse backgrounds for a common purpose.

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In order to truly understand the professions, it is necessary to understand the development of the modern professions. The early meaning of the word ‘profession’ was a declaration or promise or vow made by a person entering a religious order. By the late Middle Ages, its meaning had changed to identify that class of persons who professed knowledge of some department of learning or science, and used that professed knowledge in relating to other people’s affairs. Professions arose out of community needs. When a need arose which could not be met by members of the family, someone else in the community had to be found to solve the problem. Individuals who possessed the necessary expertise to deal with the matter would then be called in. In early times, professional knowledge was passed on from father or mother to son or daughter, or from master to apprentice. Over time, training systems were developed, and later educational institutions that offered the necessary professional specific training came into being. To maintain the standards of each professional service, to maintain training and proficiency, and to prevent malpractice within a profession, certain protective measures were developed and implemented. Leaders in that profession formed various organisations with the aim of establishing standards of practice, as well as professional codes of ethics and professional norms. Thereafter, those who wished to enter the profession and render professional services were required to comply with those specific professional standards in order to be accepted into it. These professional organisations also organised training, arranged for the examination of candidates and strove for legal recognition, in which only members of the organisation would be recognised as professional practitioners. Legal recognition and legal control over the profession would then be obtained, rendering the service a closed profession, the members of which must be registered or enrolled with the relevant professional registering body in order to practise legally. In South Africa, the Nursing Council is responsible for the registration and the annual practising certificate of the various categories of nurses.

The meaning of professionalism Professionalism and professionalisation of nurses is a growth process that can be compared to a journey and is never an end in itself. Professionalisation of a nurse is the result of assimilating a variety of influences and experiences through which the culture and value system of the profession becomes part of each practitioner’s identity. This is a process that takes place within practitioners themselves through the contact with and influence of other practitioners in the health sector with whom they work throughout their careers. Professionalism strongly relates to the attitude of persons and their willingness to make a positive or negative contribution to create a better world for all. Criteria for the professional status of nursing and midwifery in South Africa The professional status of nursing is primarily based on professional solidarity, accountability, proficiency, maintenance of a code of ethics and the welfare of the public. Midwifery in South Africa has been recognisable as a profession since 1810, when a training system, code of ethics and professional training requirements were introduced for midwives. Nursing acquired state registration in 1891 and professional status in 1944 with the promulgation of the first Nursing Act 45 of 1944. The fundamental principles upon which the professional status of nursing in South Africa is based are as follows: 33

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• Peer group control and maintenance of professional discipline by the profession itself through legally constituted institutions or bodies • A specific body of knowledge consisting of specialised skills drawn from the fields of the health, natural and social sciences • An acceptance of the social role and functions of the nurse in the community • The development of specialised knowledge based on research • The preparation of the newcomer to the profession through a specific programme of education and training.

Criteria for recognition as a profession A profession has the following: • A body of specialised theory with skills based on this theory • The development of relevant knowledge drawn from both the arts and the sciences • A prescribed period of training and learning prior to qualification • The testing of professional competence prior to admission to the ranks of qualified professionals • Some form of registration or licensure as a prerequisite for practice • Professional autonomy with control of the profession by the profession • Ethical control of the profession which is vested in the profession itself and not in an outside agency • The ideal of service to the community which is based on the needs of the patient and not on any other consideration • Accountability for professional acts • Exclusivity, based on the mastery of knowledge and skills, and the capacity to internalise and express the norms and values of the profession • Legal recognition • High social status and social power • The application of theory to practice so that the results of actions can be predicted • Ongoing critical analysis of its practice and the development of new methods in the light of new knowledge • Individuals who practise autonomously, using discretion and judgement based on knowledge and experience, with acceptance of the concept of accountability • An overriding concern for the welfare of others • An obligation to engage in lifelong learning • A constant striving for excellence. The above criteria can be applied to the nursing profession in South Africa as follows: • Through the Nursing Act 33 of 2005, the control of the nursing profession is in the hands of the profession itself. • The South African Nursing Council is the statutory body that controls the profession. This control includes the following: –– The securing of enabling legislation, in the form of the Nursing Act with its future amendments and regulations –– The issuing and publication of regulations in respect of all aspects of nursing –– The regulation of admission standards, education and training and curriculum content 34

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–– The accreditation and inspection of nursing education institutions –– The regulation of examinations conducted on its behalf and, in some instances, the conducting of national examinations for certain categories of nurses and foreign applicants –– The registration and annual licensing of nurses (annual licensing will in future be dependent on providing proof of having undergone continuous professional development) –– The keeping of registers for all categories of members. • Prospective professional nurses must provide proof of their knowledge and skills through successful completion of prescribed education and training programmes and examinations. The nurses must also comply with the standards of the profession, and strive to uphold its norms and values. • The protection of the community is ensured by the professional integrity of the nurse and by the upholding of norms and professional codes. Professional conduct hearings, which are peer-review hearings, are held in instances where malpractice is suspected in order to maintain those norms and codes. The welfare of the community takes precedence in decision making related to nursing services and takes into account the following aspects: –– The exclusive rights and privileges of the nursing profession that permit only registered and enrolled persons to practise nursing –– The recognition of nursing as an essential service in the public sector –– The responsibility and accountability of nurses for their own acts and/or omissions. • The establishment of professional associations and organisations that do the following: –– Act as spokespersons for the profession. –– Ensure the establishment and maintenance of professional standards. –– Promote the development of the profession. –– Promote the interests and the socio-economic status of nurses and the nursing profession. –– Regulate professional requirements, analyse problems and develop an appropriate approach to changing needs and structures in the health services. –– Advise on requirements in respect of education and training. –– Monitor, analyse and influence policy, regulations and legislation relating to health and nursing.

Professional conduct of nurses Professional conduct refers to the behaviour, attitudes and actions of the person registered or enrolled with the South African Nursing Council. It is the responsibility of the profession to ensure that competent nurses are available to the communities they serve – nurses who can practise with confidence, accuracy and safety. Every nurse must comply with the fundamental requirements of professional conduct, which are as follows: • The nurse is a law-abiding citizen who abides by all the laws of the land, including the Nursing Act 33 of 2005 and other health-related legislation.

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• The nurse performs his or her functions as a nurse and does not profess to be any other type of professional, such as a medical practitioner or supplementary health professional. • The nurse always lends his or her full co-operation to ensure safety and order in the rendering of health services to the community. The nurse is therefore obliged to ensure that the prescribed treatment provided to patients is correct. • Within the limits of the nurse’s scope of practice, the nurse preserves and protects the physical welfare, mental wellbeing, personal rights and dignity of the patient. • The nurse’s interactions, responsibilities and obligations to the medical practitioner, other health professionals and other health service staff are always professional. The nurse never says or suggests anything that may damage the reputation of another health professional or health service worker. • The nurse upholds the rules of professional secrecy. Whatever the nurse hears or finds out in the course of his or her duties is not retold unless it is information that the medical practitioner or other health professionals need in order to treat the patient. • The nurse ensures that he or she is always professionally competent to render safe nursing care within the scope of practice of the nurse. The nurse must be a lifelong learner to keep abreast of the latest developments in the healthcare sphere that may impact on his or her field of clinical practice. • The nurse always complies with the provisions of the Nursing Act and its associated regulations. It is important for the nurse to keep abreast of any regulations that may influence his or her practice.

The South African legal framework for nurses and midwives Based on the trust of the community, legislation controlling nursing was introduced for autonomous governance of nursing affairs and in order to protect the public. The promotion of public welfare is facilitated by the compulsory registration and issuing of annual practising certificates to all persons practising nursing. Prescribed standards and criteria that must be met before such persons can be registered further ensure that nurses practise with competence and safety. While the South African legal framework for nursing is much wider than what is discussed in this chapter, an overview of the two most important laws is provided.

The social contract in nursing and midwifery All nurses and midwives fall under an unwritten yet binding contract with the community that they serve or in which they live. A contract is an agreement that is entered into by one or more persons. It is a give-and-take arrangement: one party agrees to do something for the other party, and the other party agrees to give something in return. Both parties are obliged to fulfil the stipulations of the contract. For a contract to be valid, there must be an offer and an acceptance of that offer, which may be written or verbal. In the case of the social contract with the nursing profession, this is unwritten and it is between two groups of people, namely the profession and the community, rather than between individuals. The nursing profession agrees to offer safe, competent and ethical care in return for which the community allows the profession to function 36

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autonomously and bestows high social status upon it. This contract is established and based on the trust that the profession inspires in the community through application of its specialised knowledge and competence. The obligation of the nursing profession is to ensure that this trust and competence are maintained at all times.

The importance of legal recognition of the nursing profession For a profession to grow and develop, the community and members of the profession need to recognise its importance. The community has recognised nursing as a profession and has assigned a certain status to it. The professional solidarity and sense of identity of nurses have facilitated the autonomy of the profession by means of a prescribed scope of practice and a regulatory and professional conduct system that applies to all members of the profession in South Africa: this objective could be attained only through legislation. The Nursing Act not only serves as a binding factor for the nursing profession in this country, but also as a status symbol. Not every country has its own nursing Act; in many countries the nursing profession is legally under the direct control of the medical profession or the state. South Africa’s legislation is the Nursing Act 33 of 2005, the purpose of which is to do the following: • Place the control of the nursing profession, through legislation, in the hands of nurses who, by the same token, also exercise control over the delivery of an ethical, competent nursing service to the community. • Ensure that all nurses who practise for gain are registered or enrolled with the South African Nursing Council, thereby preventing non-nurses from practising for gain. • Provide for peer group control in the form of a nursing council. • Establish co-operation between the nursing profession and other health professions by means of a statutory relationship. • Provide for the education and training of properly qualified nurses who will make a contribution to the development of health services and provide safe nursing care to the public. Contractual obligations in the workplace In rendering nursing services, the nurse may enter into three types of contract: • A written contract with his or her employer in which the employer undertakes to pay the nurse a stipulated amount of money (remuneration) in return for services. This type of contract binds the nurse to make his or her competence available for specific hours and to put in a day’s work for a day’s pay. Should a nurse breach this contract in any way, the nurse can be disciplined or dismissed by the employer. The nurse may also be reported (by the employer or the patient) to the South African Nursing Council, which may decide to discipline him or her for failure to provide the services as promised to the employer or patient. • The nurse, as an employee of a hospital or other health service facility offering healthcare to patients, becomes a party to the contract between the hospital and the patients who are admitted to that hospital. The hospital offers admission to the patients, provision of the necessary services and care, and the protection of the patient’s safety, name and possessions. In this contract the nurse, as an employee of the hospital, acts as the agent of the hospital and enables the hospital to honour its part of the agreement by providing the care that the patient needs. Just as the 37

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hospital is committed to abide by the contract, so the nurse is committed to render the services required, because this is the purpose for which the nurse was employed in the first place. If the nurse does not do so, the patient may sue both the nurse and the hospital for negligence and for any damages and losses that the patient may have suffered as a result. This is where the concept of vicarious liability referred to earlier originates. • The nurse is party to an unwritten contract between nurse and patient. The nurse offers nursing knowledge, expertise and skills. The patient agrees by accepting the nurse’s care. In circumstances in which patients may be unconscious, confused or otherwise unable to make their wishes known or take a meaningful part in discussions concerning their care, the nurse uses professional knowledge and expertise to act in their best interests and to advocate for them. The acceptance of care is thus assumed. In return for the nurse’s care, patients offer co-operation to the best of their ability in the circumstances. In terms of this contract, patients provide information and give permission for examinations, tests and other assessments to be carried out in order to enable the nurse to determine their needs and to reach a nursing diagnosis. Discussions take place regarding the nature and scope of the nursing care required; patients are informed of this and, where possible, voluntarily participate in all nursing care activities. This contractual agreement between nurses and patients is based on mutual trust and respect, and applies to hospital and community-based nurses as well as private nursing practitioners. Nurses in private, independent practice often obtain this agreement in writing and keep a copy of the signed agreement in their patients’ files. Seen in the light that a contract is a give-and-take agreement, the only requirement from patients is to be co-operative and to provide information when required to do so. The nurse is required to provide service and expertise. This is based on mutual trust. It should be noted, however, that the basis upon which the nurse provides these services is not based solely on obligations, acts of charity and concern for humanity. The professional nurse cares for patients in return for payment and is entitled to a fair wage for services rendered. In addition, students are able to gain valuable clinical exposure and experience in order to obtain their professional qualifications. Patients pay indirectly for the nursing services they receive through taxes, minimum clinic fees and contributions to medical aid schemes. The existence of contracts, both written and unwritten, is a reality in the nursing profession. Such contracts are legally binding and the nurse is obliged to fulfil their stipulations. Failure to do so constitutes breach of contract, and workplace disciplinary, legal or professional conduct action may be taken against the nurse.

The content of the National Health Act 61 of 2003 The National Health Act 61 of 2003 provides a framework legislation, which means that it sets out broad legal and operational principles that must be fleshed out in regulations. This Act provides a framework for a structured uniform health system in order to unite the various elements of the national health system in a common goal to improve universal access to quality health services, taking into account the obligations imposed by the Constitution. The Act rests heavily on the Constitution which, among other things, requires the state to take reasonable legislative and other measures to 38

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progressively achieve the right of access to healthcare services, and reproductive healthcare, within its available resources. The Act applies to all healthcare practitioners and organisations. It covers various issues contained in the Bill of Rights, including the right to emergency care, the right of children to basic health services and everyone’s right to an environment that is not harmful to health or wellbeing. Many ethical standards have been elevated in the statute such as the recognition that all patients are to be respected as individuals, that informed consent must be sought and obtained prior to procedures, and that personal and medical information has to be protected as private and confidential. • Chapter 2 of the Act is one of the most important sections for clinical practitioners as it brings in some of the transformative elements which aim to restore the dignity of every user of health services. • Chapter 3 describes the general functions of the national Department of Health and the Director General, and the establishment of the National Health Council and the Consultative Health Forum. • Chapter 4 establishes provincial health services and outlines the general functions of provincial health departments, and establishes provincial health councils in all the provinces. • Chapter 5 establishes the District Health System. • Chapter 6 deals with one of the most innovative elements of the National Health Act – classification of health establishments; the certificate of need; the establishment of boards for hospitals, clinics and community health centres; and the relationship between the public and private health establishments. • Chapter 7 deals with human resources planning and academic health complexes. • Chapter 8 deals with complex issues such as the control of use of blood, blood products, tissue and gametes in humans. • Chapter 9 provides for the establishment of a National Health Research Ethics Council and Health Research Ethics Committees at every institution, health agency and health establishment at which health research is conducted. • Chapter 10 provides for the appointment of health officers within all three spheres of government to monitor and enforce compliance with the Act. • Chapter 11 empowers the minister to make regulations on many of the issues covered by the Act. • Chapter 12 empowers the minister to appoint advisory and technical committees, to assign duties and delegate powers, and to prescribe transitional arrangements.

The content of the Nursing Act 33 of 2005 The correct designation of the Act is the Nursing Act 33 of 2005. A full copy is accessible at http://www.sanc.co.za/publications, and you are advised to access it before studying this section. As it is often necessary to make amendments to Acts in the light of altered circumstances or to accommodate different needs, ‘as amended’ is always placed next to the title of an Act when this has been done.

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The Nursing Act 33 of 2005 is a new nursing Act, which was brought into effect after 1994. It has been implemented ‘to regulate the nursing profession; and to provide for matters connected therewith’, and it provides definitions that explain the terms used in the Act. Where the terms are also used in nursing practice or in other nursing regulations, they have the same meaning as stipulated in the Act. The South African Nursing Council is brought into being by this Act as a ‘juristic person’. The Act establishes the Council as the controlling body for nursing in South Africa, and sets out the objectives of the Council, which include the following: • Serve and protect the public in matters involving health services generally and nursing services in particular. • Perform its functions in the best interests of the public and in accordance with national health policy as determined by the minister. • Promote the provision of nursing services to the inhabitants of the Republic that comply with universal norms and values. • Establish, improve and control the conditions, standards and quality of nursing education and training within the ambit of this Act and any other applicable laws. • Maintain professional conduct and practice standards for practitioners within the ambit of any applicable law. • Promote and maintain liaison and communication with all stakeholders regarding nursing standards and, in particular, standards of nursing education and training, and professional conduct and practice both in and outside the Republic. • Advise the minister on the amendment or adaptation of this Act regarding matters pertaining to nursing. • Be transparent and accountable to the public in achieving its objectives and in performing its functions. • Uphold and maintain professional and ethical standards within nursing, and promote the strategic objectives of the Council. The specific functions granted by the Act enable the Council to achieve its objectives. These state that the Council must execute such functions as keeping registers, issuing certificates, and accrediting and inspecting nursing education institutions; and that the Council may execute such functions as recommending regulations, doing qualitycontrol inspections and owning property. The Council mandate described in the Act is executed by employees led by a registrar and a board (Council), which is responsible for determining policy. This board, under the leadership of a chairperson, consists of 25 individuals, including 16 nurses, and is appointed by the Minister of Health following nomination by the profession. The Act determines the scope of the profession and that the minister may prescribe a scope of practice for the different categories of nurses. Registration is a prerequisite for the practice of nursing in South Africa, and all categories of nurses, including students, must be registered with the Council. The Act prescribes the categories in which nurses may be registered, which are professional nurse, midwife, staff nurse, auxiliary nurse or auxiliary midwife. The staff nurse is a brand new category, the educational preparation of which will start in 2016. This initiates a new era in nursing with a transformation of the profession and the education of nurses and midwives. It does, however, mean that enrolled nursing categories will still be present for a long time as not all of them will 40

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choose to upgrade their qualifications. While the education and training of enrolled nurses terminated in 2015, they will still be allowed to practise as such and their names will remain on a register, but this will be closed for new entrants at a time determined by the Council. Nursing education and training programmes are prescribed in regulations related to the Act. All nursing education institutions and their programmes must be accredited as such by the Council as well as a higher education institution with the Council for Higher Education (CHE). Once a prescribed nursing programme has been completed, students are registered in the relevant category of nursing, following which all nurses have to pay a yearly fee to obtain their annual practising certificate. In future this certificate will be linked to proof of having completed prescribed continuous professional development. Community service for nurses is prescribed in regulations which determine that, on completion of the programme, nurses must work for one year in community service before full registration as a nurse will be awarded. The regulations currently determine that only students in the comprehensive four-year programme will be affected by this regulation. Without having completed such community service, the nurse will not be fully registered as an autonomous practitioner. The Council may withdraw or suspend registration of nurses or students for a variety of reasons as stipulated in the Act. One of these is when the Council decides to withdraw or suspend a nurse’s or student’s registration as a result of any case of improper or disgraceful conduct. Complaints and allegations of such conduct may be received in any way, for example reports submitted by the courts of nurses involved in criminal cases, complaints by the public, or reports in the media. Once a complaint or report has been received, the Council may direct that the matter be investigated. The Professional Conduct section investigates by calling for whatever information may be required to decide whether or not a professional conduct hearing is necessary. The Registrar will issue a summons for the accused and witnesses to appear at the hearing at a stipulated time and date. The hearing is conducted by a Professional Conduct Committee consisting of Council members, following which a decision is made and, where relevant, a penalty as prescribed in the Act is awarded. With the exception of the admission of guilt fine and caution, reprimand or caution and reprimand, all the penalties listed below may be suspended. This means that the penalty will only come into effect if a second or subsequent offence is committed, or if the guilty nurse does not comply with any other conditions that the Council may put as part of the sentence, such as rehabilitative treatment, the submission of regular progress reports or attending specified courses or updating programmes. Penalties provided for in the Act a. A caution or a reprimand, or both b. Suspension for a specified period from practising or, in the case of a student nurse or midwife, extension or suspension for a specified period of the prescribed period of education and training c. Removal of the nurse’s name from the register d. A prescribed fine e. Payment of the costs of the proceedings.

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Specific provision has been made to address the impairment of nurses and their unfitness to practise. Unfitness to practise may be due to physical or mental health disability or substance abuse. Such hearings will no longer form part of professional conduct hearings. In the event that a nurse is found to be unfit to practise as a nurse, one of the following decisions can be made: • Allow that person to continue practising in the profession and, in the case of a student, to continue with the education programme under such conditions as may be deemed fit. • Suspend that person for a specified period with reassessment before the decision can be reviewed, or suspend that person from practising until such time that the reassessment and review of the decision is done and, in the case of a student, from continuing with his or her education and training programme. • If a person applies for reinstatement after a period of suspension, the Council must evaluate the person’s ability to continue practising and, depending on the results, may extend or withdraw the suspension.

Clinical alert! Remember that ignorance of the law is no excuse, and ignorance cannot prevent a nurse from being held accountable for his or her acts and/or omissions. Good intentions cannot mitigate irresponsible actions, and being sorry cannot excuse unprofessional conduct.

Professional conduct action does not take place in isolation. Nurses who are involved in incidents of negligence or malpractice may also find that they are the subjects of workplace disciplinary action by their employer. The employer’s disciplinary action is taken in terms of the Labour Relations Act (LRA) 66 of 1995, and in terms of the employer’s code of conduct or disciplinary code and the nurse’s employment contract. It should be noted that, although a Council sentence may not prevent the nurse from practising, the nurse may still lose his or her job after a workplace disciplinary hearing, and it may be difficult for such a nurse to find other employment as the Council’s professional conduct matter is in the public record and the outcome of the workplace disciplinary hearing is in his or her employment records. Any person who makes out that he or she belongs to any of the categories of registered or enrolled persons, or who makes use of the titles, badges and distinguishing devices of a registered or enrolled person, without in fact being registered or enrolled, is guilty of an offence and is liable to prosecution. If such an individual practises nursing or midwifery for gain without being registered or enrolled, he or she is also guilty of an offence. It is even an offence to knowingly suggest that someone is a registered or enrolled person if this is not the case. The last chapter of the Act addresses general and supplementary provision in nursing and midwifery. Provision of the special authorisation of nurses who are required to assess, diagnose and prescribe treatment for patients in the absence of a medical practitioner or pharmacist is a special concession. This section provides for the special authorisation and licensing of nurses to diagnose and prescribe treatment following the

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successful completion of a prescribed course. Such a licence will be valid for three years and can be renewed on application. This chapter also refers to the provision of regulations, the repeal of laws, transitional arrangements and the short title and commencement of this Act. Anyone can appeal against decisions of the Council. This section of the Act sets out the process for an appeal. The right to appeal against the decisions of the Professional Conduct Committee is contained in Chapter 1 of the Act.

Regulations, codes and rules relating to nursing practice The professional practice of nursing requires that a nurse or midwife be conversant with the rules, codes and regulations that govern his or her practice. These include regulations promulgated by the Minister of Health in terms of the Nursing Act. As the conduct rules and the scope of practice regulations have a significant impact on the professional lives of nurses and midwives, all nurses and midwives must acquaint themselves with those regulations that directly affect their practice. The nurse should also be aware that all regulations are continually subject to amendment. As soon as an amendment has been promulgated, it must be complied with. Nurses who are undertaking a course of training should acquaint themselves with the regulations pertaining to the particular course in which they are engaged. This is both to protect nurses from any unfair or irregular practice and to give them a firm understanding of the objectives and content of the course from a national and legislative perspective. What the Council does not do The Council is not involved in any matters related to the following: • Employment benefits for nurses • Nurses’ salaries and salary increases • Study leave and the awarding of study bursaries • Job creation for nurses and other categories of health worker • The giving of in-service education courses • Protection of the nurse from the public • Provision of lawyers for nurses involved in professional conduct cases • Provision of professional indemnity insurance.

Government Notice R2598: Regulations relating to the scope of practice of persons who are registered or enrolled under the Nursing Act The scope of practice regulations are very important, and govern the practice of every nurse and midwife in South Africa, whether registered or enrolled. The scope of practice regulations define or describe the limits of the nurse’s practice, but they must not be regarded as being limiting, but rather as empowering. As defined in the regulations, the scope of practice of the nurse is deliberately broad. The broad guidelines set out in the regulations allow for the expansion and development of the nurse’s role in order to keep pace with technology and advances in the health field. If the scope of practice for the various categories of nurses were not broadly defined, it would probably be necessary to revise them on an annual basis, which would just cause problems and confusion. The scope of practice of all the categories of nurses are similar in that their activities 43

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are all directed at meeting the needs of the patient. The difference lies in the fact that the different categories of nurses have education and training programmes equipping them with different competencies. In addition, the enrolled categories practice under the direct or indirect supervision of the professional registered nurse or midwife, and their actions must be planned and prescribed by a professional nurse. As indicated under the discussion of the Nursing Act, reform of the profession is taking place, which includes a revision of the scope of practice of nurses for the prescribed categories of nurses in order to meet the healthcare needs of the South African population. At the time of publication, the promulgation of the revised scope of practice regulations was awaited by the profession. The structure of the regulations has been changed to reflect the required competencies of nurses and midwives clustered in competencies related to professional and ethical practice, care provision and care management, and the quality of nursing practice, which includes continuous professional development. The Nursing Act, the scope of practice regulations, the acts and omissions regulations and the ethical code form the four main pillars of the specific legal nursing framework for professional nursing in South Africa. Note, however, that all health legislation impacts upon nursing because it influences the rendering of healthcare to the patient. It is an important responsibility of all nurses to acquaint themselves and remain up to date with all legislation and/or regulations relating to their specific field of practice. Briefly, the scope of practice directs the professional nurse to assess the needs of his or her patient, develop and implement a care plan or nursing regimen for the patient, and evaluate the results of care. According to the scope of practice, nursing practice embraces the following activities: • Assessment of the patient • Identification of needs and the formulation of a nursing diagnosis • The development of a nursing care plan or regimen • Implementation of medical prescriptions and/or instructions • Administration of medication to the patient • Monitoring of the patient’s progress and his or her reaction and response to treatment • Prevention of disease and the promotion of optimum health of the individual • Offering health education and advice • Maintenance of physical comfort and hygiene of the patient • Promotion of exercise, rest and sleep • Promotion of normal mobility and body mechanics • Prevention of physical deformities due to immobility and/or poor positioning of the patient • Maintenance and monitoring of a patent airway and ensuring an adequate supply of oxygen to the patient • Monitoring and maintenance of fluid, electrolyte and acid-base balance • Promotion of optimum healing of wounds and fractures, including the maintenance of skin integrity • Maintenance of normal sensory functions • Maintenance of homeostasis and physiological regulatory mechanisms • Maintenance and monitoring of the patient’s nutrition and nutritional state 44

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• • • •

Facilitation of normal elimination Facilitation of communication Provision of psychological reassurance and acting as patient advocate Establishing and maintaining an environment that will facilitate the patient’s recovery and promote health • Co-ordinating the overall healthcare regimen and the activities of the multiprofessional conduct team related to the care of the patient • Assisting with operative, diagnostic and therapeutic procedures carried out on the patient • Support to the dying patient and his or her family, and appropriate care of the deceased patient. The scope of practice does not specify the skills and methods that the nurse should use when caring for the patient. The level of training and the experience of the nurse will determine these. The nurse may implement whatever skills he or she has been taught and in which he or she is competent, depending on the needs of the patient. This may mean that the specialised nurse will, on occasion, carry out acts that are normally performed by the medical practitioner, provided that the nurse is competent to perform them. This does not mean that the nurse is now acting outside of his or her scope of practice, but it does mean that such acts are carried out as nursing actions and are not medical care. A golden thread throughout the scope of practice that enhances other elements of patient care is the important professional competency of advocacy. Advocacy takes place at various levels, namely advocacy for the patient, for the profession, for colleagues and for oneself. Patient advocacy is about protecting the rights and dignity of patients and ensuring that they receive the best care. This includes speaking up when the patient’s care is influenced by criminal, wrongful conduct or misconduct – this is called ‘whistle blowing’, an activity of disclosure protected by law: the Protected Disclosures Act 26 of 2000. It is crucial to be truthful and sure of the facts when disclosing questionable conduct to someone in a position of trust. Professional advocacy considers the image, status and growth of the profession which, among other things, require nurses and midwives to stay updated in their area of work to ensure that they can participate in professional affairs from an informed position to influence policies governing their practice. Advocacy for colleagues and oneself does not in any way imply protecting friends by not reporting wrongful behaviour, and is essential in counteracting conduct such as workplace bullying. The nurse should, however, take cognisance of the fact that the scope of practice regulations place great emphasis on the integrity and professionalism of the individual nurse. It is the nurse’s responsibility to ensure that he or she is competent to carry out the actions which are required to meet the needs of the patient as set out in the scope of practice. If for some reason the nurse is not competent, he or she should make this known so that the regimen can be adjusted or someone else can be brought in to manage the care of the patient. It is also incumbent upon the nurse not to carry out actions that he or she is not competent to perform. If no other nurse is available, the medical practitioner should be made aware of the situation so that direct or indirect supervision and support can be given to the nurse. The nurse’s lack of training or

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expertise in a given situation does not, however, mean that the nurse can withdraw from the care of the patient: the nurse is obliged to render whatever level of care he or she is competent to render to meet the needs of the patient. Accurate record keeping is essential in all aspects of the nursing regimen. The nursing records reflect actions that have been carried out and the response of the patient. The records also provide concrete evidence of the planning and implementation of the nursing regimen.

Government Notice R767: Rules setting out the acts or omissions in respect of which the Council may take disciplinary steps This regulation relates to the professional conduct of nurses and is applicable to all nurses and midwives. Similar regulations are in force for the enrolled categories, the main difference being that the enrolled nurse and enrolled nursing auxiliary carry out their duties under the direct or indirect supervision of a professional/registered professional nurse or midwife. These rules are similar in thought and content to the rules governing the conduct of other health professionals, and contain important provisions relating to professional responsibilities, the manner in which a practice is conducted, and interaction with other health professionals. The key provisions of this set of rules are as follows: Practice

Disciplinary action may be instituted in the event that the required nursing acts related to nursing/midwifery care are not carried out, for example failure to correctly identify a patient. Nurses may not claim to perform the acts of another registered health professional such as a medical practitioner, pharmacist or supplementary health service professional. Where the treatment of the patient falls outside the nurse’s scope of practice – and this depends on the circumstances, as well as the experience, qualifications and skills of the nurse – the nurse is obliged to refer the patient for appropriate medical care as soon as possible. Any delay in obtaining such medical assistance, whether deliberate or not, is seen as a form of negligence and may result in professional misconduct and disciplinary action being taken against the nurse/midwife. This provision of the rules places a responsibility on the nurse to monitor the progress of the patient accurately and to identify problems promptly so that appropriate treatment can be given. The value of accurate records over a period of time becomes highly important when progress or lack thereof has to be determined. Failure to provide the patient’s medical practitioner with accurate and up-to-date information regarding the condition of the patient may be interpreted as being a delay in obtaining medical assistance. Nurses are obliged to do everything in their power to save lives, prevent complications and relieve suffering, whatever the circumstances and regardless of the availability of medical assistance. If a medical practitioner is not immediately available, the nurse must send for one and then do whatever he or she can to assist the patient while awaiting the medical practitioner. The nurse must always make a note on the patient’s record when a medical practitioner has been called or informed of the patient’s condition, and note the response given.

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Refusing to carry out the reasonable prescriptions and instructions of any medical practitioner who is responsible for the treatment of a patient is not acceptable. Should the nurse be unable to carry out such instructions or prescriptions for any reason, he or she is obliged to inform the medical practitioner so that alternative arrangements can be made. If the nurse feels that the prescription or instruction needs to be queried, he or she should discuss the matter with the medical practitioner and arrive at an appropriate solution. The nurse may not alter or simply refuse to carry out the prescription or instruction just because he or she feels that it is incorrect or invalid.

Prescriptions for medication Only certain practitioners such as a medical practitioner may legally provide a prescription for treatment of patients. The nurse is not legally authorised to prescribe medication and therefore changing a legal prescription amounts to ‘prescribing’ something else, which is illegal. However, the nurse has an obligation (both to the patient and him- or herself) to check that the prescription is clear, understood and within acceptable clinical parameters before administering it. If the incorrect medication is administered because the prescription was not clear, as has often happened with potassium chloride administration, the nurse will be called to account for negligence. If the patient dies, the nurse could be charged with and found guilty of culpable homicide, which is a criminal offence.

Negligence means ‘to fail to do what should have been done’ and, in the context of professional nursing, means the knowing or unknowing failure to act appropriately in relation to the patient and the nursing care of the patient. Negligence in respect of patient care, whether deliberate or not, renders a nurse liable for disciplinary action for professional misconduct. Negligence may relate to diagnosis of needs, prescribed treatment, nursing care, or observation and recording. Government Notice R387 specifically mentions the following aspects: • Wilful or negligent omission to maintain the health status of the patient, and to protect the name, person and possessions of the patient. This includes the identification, treatment and nursing of the patient, the prevention of medico-legal hazards, and the monitoring, recording and reporting of the patient’s vital signs. • Wilful or negligent omission to keep clear and accurate records of all activities carried out and observations made while caring for the patient. This includes the deliberate falsification of records and charts.

Clinical alert! A mother had complained that something was wrong with her baby in the neonatal ICU, but even though the nurses did not find anything to be concerned about, the baby died six hours later. The baby’s record had an entry at 23:50 that indicated no abnormalities, and another at 05:30 when the baby collapsed. The statement written by the nurses contained information that was not found in the record and mistakes that were corrected without being signed and dated. The excuse was that the record was not available at the time the statement was written.  ➙

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The professional nurses were found guilty by the Professional Conduct Committee of Council on charges relating to negligence – that is, failure to assess and diagnose the condition of the baby, and failure to keep accurate and clear records. The lack of recording about the condition of the baby indicated that no assessment was done or, if it was done, that it was not recorded. This led to an error in judgement being committed by the nurses about the baby’s condition and failure to call a doctor promptly. Adverse conduct

Adverse conduct refers to assault, abuse or the harassment of patients and colleagues while on duty, or any conduct bringing the profession into disrepute. Unacceptable conduct may also lead to damage to the reputation of the professional concerned. Sleeping on duty: Lawrie v Nursing Response CC and Others [2013] ZAECPEHC 47; (2014) 35 ILJ 1498 (ECP) (17 October 2013) The applicant applied to the High Court to rescind a settlement agreement concluded between the nursing agency with the assistance of a lawyer under the auspices of the Commission for Conciliation, Mediation and Arbitration (CCMA). The background to the case was that the nurse was employed by a nursing agency to work at a private hospital in terms of a labour brokerage arrangement. Her services were terminated on 26 November 2010 by the agency following a finding of ‘guilty’ during a disciplinary inquiry into an alleged misconduct of sleeping on duty. The nurse felt that she was unfairly discriminated against and referred the dispute to the CCMA. The matter was set down for 27 September 2011. The private hospital was joined for these proceedings and the nurse was represented by an attorney. A mediation process culminated in the conclusion of an agreement. The nurse referred this agreement to the High Court in view of the fact that matters relating to contracts are considered there. She maintained that the settlement agreement contained the following falsehoods: • It records that she had not been suspended, whereas she had been suspended (while the private hospital did not suspend her, the nursing agency did so). • It records that her employment was terminated as a result of the expiry of a fixed-term contract when in fact it was terminated as a result of a disciplinary inquiry in terms of which she was found guilty of sleeping on duty. In a nutshell, the court dismissed the application with costs, based on the fact that the contract was made as a result of an arbitration award in terms of section 142 of the Labour Relations Act (LRA) 66 of 1995 and the nurse should have taken her dispute to the Labour Court, which is the route specified by the LRA for labour disputes. The Labour Court has exclusive jurisdiction to rectify or cancel a settlement agreement. Nevertheless, the court considered the merits of the case, highlighting the following issues supporting the finding: • The settlement agreement in question clearly stated that this award was in full and final settlement of all disputes arising from this employment relationship. The contract was concluded and made an arbitration award in terms of the LRA, which makes it legally binding. • The settlement agreement awarded a sum of money to the nurse, which was paid and which she accepted. ➙

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• Regarding the claim of falsehoods, these statements were agreed to and signed by both parties, so that in future the nurse could avoid having to explain to prospective employers why she had been dismissed. (The CCMA indicated that disputes are frequently settled by stating in a settlement agreement a different reason for the termination of employment, which is solely for the applicant’s benefit.) • The nurse waited for more than a year to take action on this settlement agreement.

Furthermore, nurses may not allow themselves to be exploited in a way that is detrimental to professional or public interest, including allowing themselves to work for low salaries. This is a labour issue, however, and not one that should land the nurse in front of the Council. The concept of exploitation relates to the behaviour of the nurse and the way in which this behaviour reflects on the reputation of the profession as a whole. Should a nurse be persuaded or even intimidated into participating in unethical actions, or actions which bring the profession into disrepute such as the ones mentioned, the nurse may be disciplined.

Examples of exploitation If a nurse is obliged to act as an assistant at a surgical procedure in the absence of a scheduled assistant, and the surgeon pockets the assistant’s fee, the surgeon has exploited the nurse, and the nurse has allowed it to happen. Pharmacists employing nurses sometimes request them to obtain a practice number so that patients can claim from their medical aid for visiting the pharmacy clinic. Such fees then go to the pharmacy. This constitutes exploitation of the nurse’s professional status. Advertising and touting

Advertisement refers to visual or oral communication related to services provided which may not include the use of specific goods or services, or the support of any cause. Nurses may not advertise professional services in a manner that is incorrect, misleading or harmful to dignity or honour, or implies that their services are superior to others. Furthermore, touting, personally or through the mediation of an agent, is also prohibited. Nurses are prohibited from using their names and/or professional status in connection with the advertising of any service, product or institutions. Financial interest

Nurses may not accept or insist on commission or remuneration from manufacturers, or for recommendations to or from other healthcare professionals. Over-servicing, overcharging or sharing for services that have not been rendered is unacceptable. Sharing of fees collected for a service with any person other than a partner is prohibited, unless such sharing is commensurate with the extent of such other person’s participation in the rendering of such service. Professional secrecy

Information relating to patients that nurses obtain during the course of their professional duties may not be revealed. It is also a fundamental right of patients to expect that confidential information will not be repeated. 49

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Information may only be divulged with the express consent of the patient, the parent or guardian of a minor, or the spouse or children of a deceased patient, and in the exclusive interest of the patient who is not able or capable of granting permission. It is sometimes necessary, however, to divulge confidential information to another health professional, usually the patient’s medical practitioner, in order to facilitate the treatment and recovery of the patient. In this instance, the patient’s permission should be sought and an explanation given as to why it is necessary for the medical practitioner to know, although in some instances it may be appropriate for the nurse to tell the medical practitioner even if the patient does not consent, provided the information is crucial to the management of the patient. In this situation, the nurse is protected by the fact that the medical practitioner is also bound by the same stipulations regarding confidentiality of patient information. In a professional consultation situation, all information relevant to the patient and his or her management should be discussed. Certain legislation such as the Child Care Act 38 of 2005 or a court of law may also order a nurse to divulge information. The nurse may decide to maintain confidentiality despite the court order, but this renders the nurse liable to prosecution for contempt of court.

Confidentiality A doctor was charged with violation of a patient’s privacy and breach of confidentiality because he disclosed the patient’s HIV status to two other practitioners, namely a dentist and a general practitioner, without the patient’s permission. The patient was awarded R5 000 as compensation. The main reason for this decision was that the doctor had not first given the patient a chance to inform the other practitioners himself, and that he did not advise the patient that he would inform those practitioners. Relationship with other colleagues and health professionals

A nurse may not unjustly bring another professional into disrepute, nor may the nurse destroy the patient’s trust in another professional person by bringing into question the integrity, knowledge, skills or professional reputation of that individual. This provision covers a great deal of loose talk among nurses regarding the relative merits of the medical practitioners and other professionals with whom they work, and nurses need to be more careful about what they talk about and where they talk. If a disparaging remark is made about a medical practitioner within earshot of a patient, the nurse could be accused of bringing that medical practitioner into disrepute and destroying the patient’s trust in the medical practitioner. Nurses may not go into partnership or share consultation rooms with practitioners not registered under the Nursing Act without prior authorisation by the SANC. Co-operation among members of the healthcare team is essential to ensure optimal treatment of patients, and supporting or assisting illegal or unethical acts is unacceptable. Relations with the Council, its members and officials

A nurse may not hinder the work of the Council in any way, nor may a nurse bring any member of the Council, its members or officials into disrepute.

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Code of Ethics for nursing practitioners in South Africa Nursing ethics is an integral part and forms the foundation of the nursing profession as it considers principles of justice (fairness), non-maleficence (not doing harm), beneficence (doing good), veracity (truthfulness and honesty), fidelity (faithfulness to a person, cause or belief as seen through continued loyalty and support), altruism (unselfish concern for others), autonomy (allowing others to make own decisions), and caring (nurturing) – all of which influence how nurses deliver care as indicated in the Code (http://www.sanc.co.za/policies.htm). The Code of Ethics serves as a declaration by nurses and midwives that they will always provide due care to the public and healthcare consumers to the best of their ability while supporting each other in the process.

Professional associations and organisations Professional associations and organisations are essential for the ongoing growth and development of the professions by which they have been formed. Legal recognition of a professional association may be granted by means of an Act of parliament such as the Non-Profit Organisations (NPO) Act 71 of 1997, or such recognition may be de facto in that the association or organisation is recognised as acting on behalf of the profession by employers and others who have dealings with the profession. There are therefore two types of organisations, namely those protecting the public, such as the Council, and those considering the interests and protection of practitioners, such as the Democratic Nursing Organisation of South Africa (DENOSA) or a specialist professional society. The primary objective of a nursing association/organisation is the promotion of nursing and the development and maintenance of an appropriate professional ethos and culture. The secondary objective, which flows from the primary one, is the promotion of the health of the population. Generally the objectives of a nursing association/ organisation include the following: • To develop and promote an efficient and effective nursing and midwifery service in and for the community • To enhance the status of the nursing and midwifery professions, to uphold the integrity of these professions, and to promote their interests • To evaluate all matters that affect the nursing profession and to take appropriate action • To promote the rights, interests and socio-economic status of every member of the profession.

Trade unions Trade unions are organisations formed by workers in a particular occupation or institution. All trade unions must be registered with the Department of Labour in terms of the Labour Relations Act (LRA) 66 of 1995. Their primary function is to negotiate favourable conditions of service for their members by means of collective bargaining, and many gains have been made in favour of health workers in South Africa by the trade unions. Unions further assist with managing workplace issues such as disciplinary hearings and disputes to work toward a harmonised workplace. Although most unions 51

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have a code of conduct to which members must adhere, such codes of conduct are not always as all-embracing as a professional code of conduct and ethics. In the public service, it is mandatory for all employees, including nurses, to belong to a union if they wish to avoid paying agency fees set at a percentage of the individual’s salary. Some professional organisations, such as DENOSA, combine both union and professional organisation functions in one organisation.

Functions of a professional association/organisation Based on the objectives of professional associations/organisations, the primary function of such an association/organisation is the promotion of nursing, which in turn contributes to the welfare of the community. A professional association/organisation does the following: • Acts to promote solidarity among its members and to remain in touch with the community and with issues that affect the health of the community. • Develops a professional identity by restricting membership to members of the nursing profession. • Increases the service potential of the profession by –– making educational programmes and ongoing training programmes available to members –– promoting the recruitment of nurses –– conducting research into any factor or issue that may be detrimental to the profession –– keeping abreast of current developments in related professions, such as medicine, pharmacy, general education and law, and analysing the impact of such developments on nursing –– monitoring any factors such as health and illness patterns and socio-economic issues which may impact on the health of the population and consequently upon nursing –– monitoring the quality of nursing education in the country, as well as the accreditation system and the requirements for entry to the registers and rolls –– monitoring the professional conduct system –– evaluating the general socio-economic status of nurses –– evaluating the delivery of nursing services to the community. • Protects the nurse against exploitation and hazardous employment situations by lobbying for the promulgation of appropriate legislation to alleviate or prevent these problems. • Promotes the objectives of the profession with regard to the social system of the country, and constantly keeps the welfare of the community in mind. • Negotiates on behalf of its members to secure improved salaries and employment benefits. These negotiations are not solely concerned with salaries but include other benefits such as professional indemnity, group and personal accident insurance, and other similar benefits that may be necessary or advisable. • Establishes and administers nursing agencies.

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In order to enhance their usefulness to the profession, professional associations/ organisations often establish a national network of branches and subgroups that facilitate communication at grassroots level and help the professional association/ organisation to remain in contact with the membership and the issues that impact on the professional lives of members. Specialist subgroups may also be formed to enable issues affecting interest groups within nursing to be discussed and dealt with. Their functions would be the same as those mentioned above. International affiliations may also be entered into to facilitate the exchange of information and to keep up to date with new developments in the profession and in related health professions. Examples of such international affiliations are the International Council of Nurses, the International Cancer Association and Public Services International. An important aspect of the role of a professional association/organisation is the development and dissemination of nursing literature. All professional associations/ organisations publish professional journals or distribute newsletters. Many professional associations/organisations will also disseminate other popular international journals. Research is another important aspect of the role of the professional association/ organisation. The professional association/organisation should be active in encouraging and funding research, and the publication of research reports. The association/ organisation also has a responsibility to analyse and interpret the results of research, both nationally and internationally, in order to determine the applicability of such research in the South African situation. Professional associations/organisations are deeply involved in the ongoing development and maintenance of standards of practice in the country. Under the aegis of the professional association/organisation, a continuing debate relating to standards of practice and ethical matters is maintained; this promotes awareness of these matters in the minds of nurses and helps to develop the profession.

Professional indemnity An important benefit arising from membership of a professional association/ organisation is professional indemnity. Professional indemnity provides the nurse with legal advice and assistance should he or she be involved in malpractice, cases of misconduct or incidents of negligence. Many employers require proof of professional indemnity before they will consider a nurse for employment. Industrial action It is not infrequent that, in the course of salary and benefit negotiations, the possibility of strike action or some other form of industrial action is mooted. While strike action by nurses is no longer a criminal offence, and the Constitution of the RSA, 1996 declares it as a right, using the welfare of the patient as a bargaining counter remains an ethical issue for nurses. Should industrial action be embarked upon, strong leadership is required on the part of the professional association/organisation/union to ensure that the patient’s rights to care are upheld and the action attains its objectives while remaining within the bounds of professional norms and ethics. Nursing and all health services have been declared essential services in the public sector, thus effectively removing the right of nurses to strike. Labour legislation provides for compulsory arbitration in the case of disputes in essential services. 53

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Nurses should also bear in mind that instances of neglect of patients occurring during industrial action might render them liable to disciplinary or professional conduct action.

Conclusion While legislation for the nursing profession has been discussed in some depth in this chapter, nurses should note that all health legislation impacts on the practice of nursing because it influences the rendering of healthcare to patients. It is an important responsibility of nurses to acquaint themselves and remain up to date with all the legislation and regulations that relate to their field of practice.

Suggested activities for students Activity 2.1 It is generally argued that nursing is not really a profession. What are your views for and against the above statement? In your arguments, compare nursing with other professions.

Activity 2.2 Divide the class into two groups and, in an organised debate, prepare and role-play the benefits of a professional association/organisation when compared with those of a trade union. The debate must be explicit in relation to the control of the nursing profession, and the legal and ethical implications on the association’s as well as the trade union’s functioning. One group must argue for trade unions while the other argues against.

Activity 2.3 Analyse the case study on sleeping on duty (on page 48), and do the following: • Identify the lessons learned from this case study other than that one should not sleep on duty. Did this nurse bring the profession into disrepute? Support your response. • ‘The nurse was unfairly treated’. Divide the class into two groups and, in an organised way, debate this statement, with one group supporting it and the other group not.

Activity 2.4 Discuss the relationships inherent to the application of the Code of Ethics for nurses and midwives. Why is it important?

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Learning objectives On completion of this chapter, the student should be able to do the following: • Provide an ethical service as demonstrated by his or her ability to explain, analyse and apply aspects of the ethics of nursing to the nursing practice, as well as integrate these with his or her personal norms and values. • Demonstrate an understanding of the philosophical basis of nursing. • Define personal norms and values, and relate these to the nursing situation. • Identify the basis on which personal norms and values are established. • Maintain high standards of professional behaviour and avoid unethical behaviour. • Participate in the discussions relating to ethical issues/dilemmas, and bring a nursing perspective to bear on ethical decision making. • Be vigilant regarding the rights of patients, particularly the very vulnerable who are unable to speak for themselves.

Key ethical principles Ethical concepts in nursing underlying basic nursing care are as follows: The principle of respect for persons This includes: • The duty to respect the rights, autonomy and dignity of others • The duty to promote the wellbeing and autonomy of every individual • The duty to be truthful, honest and sincere, as deceit is dishonourable. The concept of a person as a bearer of rights and duties is a fundamental principle in ethics and law, as well as politics. The principle of justice This includes: • The obligation of universal fairness or equity • The duty to treat people as individuals and in themselves, and not as a means to an end ➙

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• The duty to avoid discrimination, abuse or exploitation of people on the grounds of race, age, sex, sexual orientation, gender, social class or religion. The principle of justice requires that, at least in theory, any personal guidelines for action should be capable of being generalised to all people. For this reason, the principle of justice is sometimes described as the principle of universality. The principle of beneficence and non-maleficence This includes: • The duty to do good and to avoid doing harm to others • The obligation of advocacy and the defence of the rights of the weak and vulnerable. ‘Do unto others as you would have them do unto you.’ This principle is sometimes referred to as the principle of reciprocity.

The principle of confidentiality This includes the duty to keep all information about the patient confidential. This is closely related to fidelity, which is about keeping a promise or secret. When a patient is admitted to hospital, an unwritten agreement to look after his or her wellbeing and to keep all information about his or her illness and diagnosis confidential already exists.

Key concepts and terminology Bullying: Unwanted, offensive, intimidating, aggressive insulting behaviour or an abuse of power by one group or person against others. The behaviour is ongoing, leaving the target feeling upset, threatened, vulnerable and humiliated in the long term, undermining their self-confidence. Ethics: Viewed as the science of morals and therefore ‘ethics’ means character or habit. An ethic is ‘what ought to be’. Ethos: A concept that is indicative of the moral attitude, ideals and customs of humankind. Morals: Standards of behaviour reflecting right and wrong. Norms: Recognised standards or patterns. Rights: Moral or legal entitlements to have or do something. Values: A worthwhile or desirable set of standards or qualities. Value judgements: Consist of personal and objective value judgements. A personal value judgement is subjective because it is based on personal values and therefore is a personal choice or preference. An objective value judgement is independent of the person making the judgement and is found, for example, in research projects where information is evaluated and described objectively.

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Prerequisite knowledge The nurse should have knowledge of the concept of human rights as contained in the Constitution of the Republic of South Africa.

Medico-legal considerations Nurses are accountable to the community they serve for the way in which they fulfil their responsibilities in nursing and healthcare. They may be called to account for their behaviour by the courts of the country and the nursing profession.

Key ethical considerations Ethical norms, values and principles are all based on the great unifying principle that is to be found in all the major religions and belief systems, namely to treat others as you would like to be treated.

Key legal considerations • Application of the principles of patient advocacy may result in conflict with other health professionals, particularly if their approach and perspective differ from those of the nurse. • Conflict may also arise where the rights of the patient are being violated through the actions of another health service practitioner. • The response to unethical behaviour on the part of a colleague or other health service professional has legal implications. • Obtaining truly informed consent from the patient or the patient’s family is a legal requirement. • The major ethical principles of nursing are enshrined in the legislation which governs nursing and healthcare in general, namely: –– confidentiality, which means the protection of the name, person and possessions of the patient –– patient advocacy and the protection of the vulnerable –– ensuring that all the needs of the patient are met –– accountability, honesty and integrity in all that the nurse does –– the duty of the nurse to take due care in all his or her activities –– obtaining consent for nursing and healthcare interventions.

Essential health literacy The ethical principles of beneficence, autonomy, justice, veracity and fidelity must be observed when health education is given, with particular consideration of language used and the cultural practices of the patient. ➙

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Patients must have an understanding of their rights and responsibilities as consumers of healthcare to ensure that they are enabled to make the best decisions for their health.

Nursing implications Be sure to clarify your values and opinions on controversial issues to guide you during decision-making processes in ethical dilemmas. You always remain accountable for your acts and omissions.

Introduction Ethics is viewed as a science of morals because it relates to human behaviour, norms and values. In nursing, ethics relates to the nurse’s behaviour in the care of his or her patient. Related concepts are ‘doing good’ and ‘preventing damage or harm’. In this chapter, the nurse will be exposed to the major philosophies of nursing and will be encouraged to use the principles contained in these philosophies to develop a personal perspective of nursing. The nurse will also be introduced to the concept of human rights, ethics in nursing and to ethical dilemmas related to the fields of health and nursing, thus demonstrating skills that will address these dilemmas in a way that upholds the rights of the patient as well as the norms and values of the nursing profession. The use of critical and reflective thinking in the context of ethics and ethical dilemmas will enable the nurse to develop self-assurance in making decisions that are in agreement with legal prescriptions and in harmony with the spirit of the nursing codes of ethics.

The philosophical basis of nursing ‘Philosophy’ is derived from the Greek words phileo meaning ‘love’, and sophia meaning ‘wisdom’. Philosophy, therefore, means love of wisdom. From this concept comes the idea that through philosophy one attempts to understand oneself and one’s life, therefore among the questions that are asked is: ‘What is the purpose of human life and activities?’ The principles and values in accordance with which one lives have their origin in philosophy. One’s outlook on life determines one’s ideals and the manner in which those ideals are attained. A meaningful philosophy of nursing is based on a healthy philosophy of life. A nurse’s personal philosophy encompasses a view of his or her own life and that of others, as well as a view of the meaning of his or her life and the lives of patients. The nurse’s attitude to life determines his or her approach to life in general and the nursing profession. Philosophy lends meaning to nursing. A dedicated nurse should have a definite philosophy that directs his or her vision and values in respect of choices and actions in nursing. If a nurse has no personal or professional philosophy of life, nursing care degenerates into a series of tasks to be carried out. A nurse’s view of nursing is largely influenced by the period in which he or she lives. The value system of nursing is linked to the way in which the community sees and 58

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evaluates things, and the way thinkers in the community understand events, actions and concepts. In nursing there has always been a separation between the reality of science and the values of philosophy. On the one hand there is science, which studies and describes factual data, and on the other hand there is philosophy, which examines values. Philosophy seeks to investigate the ‘what’ and ‘why’ of nursing. This philosophical approach is not concerned with the scientific process of experiments, observations, descriptions and comparisons, but with the meaning and purpose of the life of the nurse and the patient. It is therefore based on value judgements.

Philosophical schools of thought The philosophy of nursing is not based on the school of thought of a single philosophy. Nursing borrows concepts from various philosophical schools, and combines them into a philosophy of life that finds expression in the nursing profession. Philosophical influences such as those of naturalism, idealism, realism, theistic realism, pragmatism, humanistic existentialism, asceticism and romanticism are all encountered in a philosophy of nursing. Naturalism

A naturalist thinker believes that reality and nature are the same. Nature represents the full truth, and there is no truth, fact or eventuality that can be explained independently of nature. Naturalism maintains that nature is representative of reality as a whole. The phenomenon of cause and effect, which forms the basis of naturalism, excludes the divine element. The following are examples of ways in which naturalistic thinking may influence nursing: • Modern biochemistry, biophysics, histology and genetics, all of which are important for the development of medical science, tend to cause the development of the naturalistic view of life on the part of health workers. Nurses practise their profession in a highly scientific environment, and some nurses are inclined to view science as the only source of knowledge and to regard humankind as merely an earthly organism. • Florence Nightingale viewed nursing as placing the patient in the best condition so that nature could have an effect on him or her. The process of natural immunity, which is a fundamental concept in medical science, as well as the tendency to encourage natural wound closure, falls under naturalism. • A fundamental principle in medical science and nursing science is to understand the scientific method and to apply it properly. This method is characterised by thorough observation of a phenomenon, accurate description thereof and the cautious formulation of generalisations. It finds implementation particularly in the scientific nursing process and research. Idealism

In contrast to naturalism, which maintains that everything can be explained by the way of the factual and concrete reality of nature, idealism advocates subjective experiences, ideas and thinking. To the idealist, reality is that which can be observed, irrespective 59

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of whether it is experiences, ideas, emotions or one’s free choice. Because personal experience is reality, the idealist sees the self as the fundamental reality. Concepts of importance in the philosophy of idealism are perfectionism, balanced individuals and communities. Individuals ought to live in harmony with others, showing mutual respect and thoughtfulness. No one may be regarded as more important than another. The idealist has an innate need to do good and continually strives for the attainment of the abovementioned ideals. Within this subjective experience of reality, the idealist can also accommodate the highly scientific progress and conditions. A nursing philosophy based on idealism should focus on the nurse’s spiritual, moral, intellectual, emotional, physical, social and professional experience. These factors form the basis of quality nursing. For the nurse, the following conclusions may be drawn from idealism: • Every individual is a feeling person with emotions and the ability to evaluate, judge and display a reaction. • The free will is the true determinant of behaviour. Whenever nurses exercise their free will in respect of ethical choices, their decision must always be in the best interest of the patient. While this does not mean that nurses have to be involved in ‘choice for the termination of pregnancy’ services if they have a moral objection, for example, it does mean that, on employment, the nurse must advise his or her employer of this objection so that the employer can place another staff member in the unit who does not have such an objection to provide the service that the patient has chosen. • People have a soul and a body. The immortality of the soul makes it possible for a person to develop to perfection by way of an ongoing process. • According to the Christian ideal, humanity’s highest goal is perfection in the image of God as personified in Christ. The concept of the perfect nurse, who performs his or her life task in accordance with the ideals of his or her faith, still exists. Such a nurse’s value to the community is inestimable, not least as a role model for the student nurse. Realism and theistic realism

Realism stems from naturalism. Both schools of thought emphasise clear, discernible orderliness in the universe. Realism maintains that experiences are the real, independent facts of the external world. There is no room for fantasy. Some realists believe in a God, some do not, and some see the world as a reality as described by science. Idealists are often also realists. Theistic realism has taken a stand on faith. It emphasises the supernatural without eliminating the importance of the natural world. The Christian philosophy essentially believes in a personal God, the Creator of humankind and the universe. The philosophy revolves around people’s lives in the hereafter and their existence on earth. People are made in the image of God with the purpose of serving Him on earth and ultimately attaining eternal joy in heaven. Humankind was created with a body and soul, an intellect and a will.

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The philosophical schools of thought of realism and theistic realism influence nursing as follows: • To the realist, the social values are vested in the individual and in the physical world. Retaining nurses in the health system requires that they be encouraged in terms of economic reward as well as sound social relationships. • Realism clearly emerges in the logical basis of the nursing and nursing education systems. The nursing system arises out of the centuries-old health needs of people, ranging from the simple to the complex, which must be met. The main aim of the nursing education system is to prepare the nursing student as a person and as a nursing practitioner in the social, spiritual and moral spheres by way of guidance, instruction, discipline and participation by the student. • Theistic realism clearly emerges in the philosophy of the religious nursing orders and services. Theistic philosophy holds that people are personally liable for their actions. Their intellect directs their actions. Because of their conscience and free will, people are responsible for their behaviour, which must comply with norms arising out of moral law. Pragmatism

Pragmatism maintains that the meaning of an idea can be determined by implementing it in practice in the objective world of actualities. Pragmatism also implies objective ways of testing an idea. It therefore requires the recognition of a problem, the formulation of a hypothesis, the collection and analysis of data, and the testing of the hypothesis. The only true solution to a problem is that which works in practice. The influence of pragmatism on nursing is illustrated in the following examples: • A pragmatic solution to the shortage of nurses is, for instance, the employment and training of nursing auxiliaries and other mid-level and ancillary health workers. Nursing auxiliaries, other specialised technical experts and ancillary workers have been appointed to meet the nursing requirements. The World Health Organization (WHO) has developed a policy called ‘task shifting’. To address shortages of healthcare staff, tasks are ‘shifted’ to less-trained practitioners to lighten the burden of the more specialised or registered practitioners. • The emphasis of pragmatism on practical feasibility has given rise to the fragmentation of healthcare. As a result, the problem, the illness and the diagnosis are emphasised, rather than the individual or family including their needs. In pragmatism, the holistic approach to nursing is lost. Humanistic existentialism

Humanism emphasises humanity, human worth, beauty, ideals and the importance of human existence. It is characterised by the value system that affords high priority to caring and attentiveness towards people. Existentialism views the existence of humanity as the centre of all things. Every person is a unique individual with free choices. This school of thought has a definite holistic view of humanity and asserts that people are not observed outside their existence. Every person is unique and is influenced by his or her environment and total existence, therefore an individual must always be regarded and approached as unique. No two persons are alike. 61

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The influence of humanistic existentialism on nursing is illustrated by the following examples: • Nursing recognises the uniqueness of every patient. Adherence to this philosophy requires that the nurse recognise the person’s complexity, nature, humanity, experience and evolution. • Stereotyping of patients is rejected. The patient must be treated as a complete whole in the realisation that a person’s biological and psychosocial composition is just as unique as his or her genetic structure. Emphasis on diagnosis should not be so strong that the person as a whole is not taken into account. • In terms of humanistic realism, the ideal in nursing is comprehensive patient care. This includes physical, psychological, spiritual and social care. This implies that the patient is at the centre and must always be treated with respect. Asceticism

Asceticism is based on the philosophy of dualism. This means that the body and soul are separate units continually in conflict with each other. Asceticism has been linked to most major world religions, including Buddhism, Hinduism, Islam, Judaism and Christianity – all of these have special ascetic cults or ascetic ideals. Asceticism is the practice of austere self-discipline, voluntarily undertaken, in order to achieve a higher or spiritual ideal. The term is derived from the Greek askein, which means ‘to practise an art or skill’. Later in Greece the term took on a broader meaning of ‘exercise’, so the early ascetics were skilled in athletics and military arts. Essentially, it is the belief that comprehensive self-denial and strict self-discipline help bring about spiritual peace that will bring one nearer to God. Christian nursing orders and missionaries are examples of this. The influence of ascetic thinking on nursing is illustrated in the following example: Because, in southern Africa, nursing is commonly linked to the Christian faith, nursing is seen as a vocation – one that expects self-sacrifice and unselfish service of a nurse. Romanticism

Romanticism is a tendency rather than a philosophy. In nursing, the romantic tendency came strongly to the fore with the public romanticising of Florence Nightingale. After her good work in the Crimean War, ‘the lady with the lamp’ gained a higher significance and nurses were seen as ‘ministering angels’. This romanticisation of nursing led to thousands of young women entering the nursing profession. A woman’s tactfulness, her protective tenderness and willingness to help became the most important characteristics of future nurses. As a result of the exploitation of nurses during the romanticisation of nursing, pragmatism began to overshadow romanticism. Nursing is now a profession in its own right with a self-regulating body (the South African Nursing Council), professional organisations and trade union representation. Although the provision of nursing is currently strongly under the influence of a theistic humanistic existential philosophy, the approach to the organisation and development of nursing must be pragmatic.

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Introductory ethics Legislation or the law enforces high behavioural standards, namely ethics. The law seeks to control extremes of behaviour. People usually come together to decide on certain actions that must be done or not done. This, in essence, is the development of norms, values and culture. In that decision, people even decide on rewards and punishment as well as actions or behaviour to be adopted. Ethics (what is desired) and law (what is mandated) are found along a continuum of human behaviour and ways to solve conflicts between humans. This concept of a continuum can be compared with a variety of issues that nurses work with on a daily basis. For example, in the diagnosis of anaemia, all people have a haemoglobin level that can fluctuate between normal values, but bio-medical scientists have together drawn a line to say that ‘a person is anaemic when the haemoglobin level is below 11g/dL’. This line is drawn because at this stage the condition becomes pathologic and makes a person feel ill. The same happens with the law and ethics: the line is drawn when a law is written and promulgated and when a behaviour is sanctioned as either good or bad. At the point where the line is drawn, the guide for ethical behaviour becomes a legally mandated behaviour. This arbitrarily drawn line can move up and down along the continuum as laws change, as new rules develop and every time that the appellate court writes a decision. The legislators then authorise specific people to enforce the law in contrast with ethics, which seeks to persuade and not force people to live without fear.

Ethics The word ethics has a variety of meanings which all relate to the principles that govern people’s conduct or behaviour. An ethic is ‘what ought to be’. ‘Ethics’ means character or habit. Ethics is viewed as the science of morals. Ethics is linked to the sciences that deal with human behaviour and character, and for this reason many scholars refer to ethics as being moral behaviour, norms and values. Ethics as a science can be traced back to the first time humankind asked the question: ‘Why?’ – ‘Why this way, and not another way?’ The study of ethics has to do with right and wrong actions and behaviour. Some aspects of moral behaviour are changeable, and are influenced by factors such as customs, tradition, codes of conduct, and the times and circumstances. Some acts, however, are universally regarded as being right or wrong. For those groups of health practitioners, such as nurses, who are closely related to life and society, ethics refers to moral practices that relate to ‘doing good’ and ‘preventing damage or harm’ to other people. Nursing has to do with people – sick or healthy – and has the power to do good or harm. There are many opportunities in nursing to do good or harm to patients. A nurse who informs a patient fully about prescribed treatment is doing good, whereas if the information is withheld, the patient may be harmed. Ethics inquiry helps nurses to understand the moral dimensions of human conduct and to formulate their responses to significant questions about human welfare. The science of ethics Ethics can focus on several areas of inquiry. Normative ethics is the study of human activities in the broad sense in an attempt to determine the standards or norms or 63

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criteria for the right or wrong behaviour – it attempts to establish what is right and wrong for the people that we come in contact with through using ethical theories such as utilitarianism, naturalism, formalism and pragmatism. Normative ethics is about the assessment of the moral importance of perceived duties and obligations in human interaction, and theories for moral human conduct are used to support one normative position rather than another. Normative ethics also includes the consideration of the legal implications of practice. For nursing practice, it will consider issues such as what the scope of practice of nurses should be after having completed various education and training programmes; or when a nurse can be legally regarded as having been negligent. Professional ethics is a type of normative ethics which applies ethical principles and rules that will determine which actions are right and which are wrong for the profession.

Common moral theories used in normative ethics (Fry 1996: 21) • Utilitarianism: A theory that maintains that the moral rightness of actions is determined by their consequences. Desired consequences are an increase in the non-moral value produced by actions, such as an increase in health, pleasure or knowledge. • Naturalism: A theory that maintains that humankind has been created with identifiable tendencies toward certain values. This includes the inclination toward community, respect for the rights of others, honesty and a just government. Ethical principles and rules about what people ought to do are derived from these tendencies. • Formalism: A theory that maintains that the moral rightness of actions is determined by their nature or their form. Desired nature or form includes the keeping of duties or special obligations (parent to child) and following certain rules, such as keeping a promise. Actions are morally significant if their form honours duty or follows the principle or rule. • Pragmatism: A theory that maintains that the moral rightness of actions is determined by what works or is most useful. Desired results are those that are practically significant or that serve a useful function. An action has moral meaning or value if it is practically significant.

Non-normative ethics includes descriptive ethics and meta-ethics. Descriptive ethics investigates and explains the phenomena of moral beliefs and behaviour of different cultural, religious or social groups. This includes, for example, the meaning that these groups attach to illness or suffering. Nurses work with many groups of people who may respond differently to illness and suffering. If nurses understand other people’s beliefs of how they should act or what is right for them, this will assist nurses to make appropriate healthcare decisions. Meta-ethics analyses the moral language and concepts used in ethics inquiry and the logic of moral justification. It is a secondary level of inquiry that provides theories about ethics rather than theories for ethical conduct. It would typically analyse the connections between human conduct and the logic of moral justification, ethical beliefs (values) and the facts of the real world, and the moral language of the nurse, so this not only investigates what is right or wrong but also seeks justification for why something is right or wrong. 64

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These forms of ethics are closely related, and their interactions yield a system of applied ethics. Descriptive ethics may first be used to describe a moral phenomenon such as protecting patients from harm, then normative ethics is used to argue for the moral accountability of the nurse in patient care, and finally meta-ethics is used to explain the meaning of accountability within nursing practice. The results of this process can then be applied to the clinical nursing care situation.

Morals Morals and morality include personal values and rules of behaviour. Morality also refers to the rules of conduct that control social interaction. The concept of morality may also embrace the mores of a specific cultural group, based on religion and/or ideology. Ethics and morals are often viewed as being synonymous and referred to as having the same meaning. Morals, however, may be described as the ‘must’ and ‘ought to’ of life, whereas ethics are the ‘why’ and the ‘wherefore’ of morals. The moral, for example, will be that all patients must be treated with respect, and the corresponding ethical question will be why all patients must be treated with respect. The word ‘moral’ refers to moral principles or morality. In nursing practice, morals are concerned with what the nurse must and ought to do. The duties of the nurse have moral and legal dimensions. The nurse has, for example, a moral and legal obligation to avoid medico-legal risks. Reference is also made to nursing as a moral art. In other words, the intelligent and humane application of knowledge and experience in nursing is the moral art of nursing. Values A value is a worthwhile or desirable standard or quality. Values represent a way of life. They can be expressed in language, in behaviours or in standards of conduct that a person endorses or tries to maintain. Values are organised into a system that has meaning for an individual. This system of values is a set of beliefs that the individual believes to be true. Some values are more important than others and are prioritised higher within the individual’s value system. This hierarchy usually becomes fairly stable over time, but other values can and do replace higher values based on life experiences and the individual’s reassessment of his or her values. Values may also be personal, or group inclined, such as institutional, professional or cultural values. Personal and group values may be shared or may cause conflict. Values may be of a moral or non-moral nature. Moral values are the values that are ascribed to human actions, behaviours, institutions or character traits. For example, the nurse who values the protection of foetal life does not want to participate in termination of pregnancy procedures because he or she believes that it is the right thing to do as it preserves life. Non-moral values are values that relate to personal preferences, beliefs or matters of taste. Personal values are beliefs and attitudes held by an individual that form a basis for behaviour and the way in which each of us experiences life. The development of values arises out of a person’s life experiences and is closely related to that person’s identity. Every person discovers his or her own values as life progresses. Every person therefore

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has a personal value system that is influenced by the value system of civilisation and the society in which the person grows up. Cultural values are values that are indigenous to a culture or people. Cultural values have an influence on people’s beliefs about health, illness and what is morally required behaviour in providing healthcare. All cultures value health to some degree. Nursing is practised in many different cultural and value systems. Western cultures value individual choice more than obedience to authority. Some Asian cultures value the elderly in the community more than other cultures. Many cultural values stem from religious beliefs and may be acted out subconsciously by individuals. Such values are deeply embedded in the background and experience of the person and cannot be questioned without questioning that person’s very self-concept. Most religions, for example, adhere to certain tenets that influence beliefs on life and death and the importance of the afterlife. The teachings of some orthodox religions embrace every aspect of human activity. In Orthodox Judaism, there are specific values and principles that are embodied in specific laws including those governing the preparation of food. Hinduism is a diverse set of religious beliefs that gives spiritual meaning to individual attitudes and acts towards others. Islam requires its adherents to submit themselves to the will of Allah in all aspects of living. Professional values are those general attributes prized by a professional group. These values are promoted by professional codes of ethics and practice. Student nurses learn about professional values from both formal instruction and informal observation of practising nurses, and gradually incorporate these values into their personal value systems. Some traditional professional values in nursing are non-moral, such as cleanliness, efficiency and being organised. Other professional values are moral in nature and include honesty, competence, compassion and steadfastness. Value judgement

Whenever a choice must be made, a value judgement is always an issue. If a person attaches a high value to something and regards it as important enough to gain more information about it, this new information becomes part of that person. It leads to the development and expansion of the person’s conscience, self-awareness and relationships with people and objects. These perceptions, this investigation of values, and this assimilation and implementation of knowledge make rational choices possible. Although rational choices are based on factual information, there is always a subjective component to this. In nursing practice, nurses are continually making value judgements, but not always on a conscious level. A nurse’s value judgement depends on what that nurse’s conception of patient welfare is and the varying situations that the various patients may be in. The nurse’s understanding of health and illness also influences his or her value judgement. As a result of the nurse’s knowledge of sepsis and its prevention, for example, the nurse’s value judgement will cause him or her to decide to use aseptic technique while doing a wound dressing. There are two forms of value judgement, namely personal value judgement and objective value judgement. In a personal value judgement it is difficult to determine the correctness of the judgement because it is a personal choice or preference, neither can the judgement be generalised and made applicable to everyone. In contrast to the

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personal value judgement, the objective value judgement stands independently of the person making the judgement. Objective value judgement is found in research projects where information is evaluated and described objectively. Value conflict

Both moral and non-moral values can cause conflict with one another and with the patient’s rights and professional duties. Personal values may conflict with professional values, which in turn may conflict with cultural values. The nurse’s value of doing good to the patient might conflict with the value of honouring the patient’s choices or his or her right to make them. The nurse’s value of giving safe medication might conflict with the patient’s value of relief from pain and the perceived professional duty to relieve suffering. The patient’s right to get out of bed whenever he or she wants to might conflict with the institution’s value of patient safety achieved by the side rails on the bed of an elderly patient. A person’s character is determined by the value choices that are made, and so is the nurse’s nursing character, which is determined by the value choices made in practice. In practice, the nurse is often confronted by value choices, and in each of these situations the nurse must first identify the values involved, the value of the relevant rights and duties, and where a conflict between values, rights and/ or duties is occurring. The nurse must then make a decision based on which values are most important. When moral values, rights and duties are involved, resolving value conflict becomes a complex ethical decision-making process.

Ethos The concept of ethos is indicative of the moral attitude, ideals and customs of humankind. Ethos is a Greek word referring to the ‘nature’ and ‘characteristics’ of something. In nursing, ‘ethos’ refers to the nature and characteristics of nursing. It encompasses the meaning and composition of nursing and is also concerned with the origin, development and extension of nursing. It is thus a far broader concept than ethics, although nursing ethics is an important component of nursing ethos. Nursing ethos is determined by the perceptions and responses of both society and the nursing profession to people’s need for healthcare. From the earliest times of the ‘primitive mother’ up to the contemporary highly scientific nursing practitioner, everyone who nurses has been spurred on by a common driving force that is based on compassion, sympathy, empathy, concern, love and goodwill towards the sick person.

Ethical principles in nursing The ethical principles of nursing are based on the concept of ‘doing unto others as you would have them do unto you’. This includes such concepts as honesty, telling the truth, self-control, love, responsible action, magnanimity, fairness and the alleviation of pain and suffering. The ethical principles on which nursing is based are beneficence, justice, autonomy, veracity and fidelity.

Beneficence Beneficence is the obligation to do good and to avoid harm. Nurses help others to gain what is beneficial to them, which promotes wellbeing and reduces the risk of harm. In

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nursing, the avoidance of harm is balanced by the provision of benefit. The acceptable ranges of both benefits and risks of harm are established by standards of nursing practice and the professional code of ethics for nurses. Nurses should establish what the boundaries of their obligation to provide benefit and avoid harm are – is it only the identified patient or anyone who might profit from nursing care and attention?

Justice Once the boundaries of the obligation to provide benefit and avoid harm have been determined, the distribution of the benefits and burdens among patient populations becomes the nurse’s concern. How can available healthcare resources be distributed fairly and justly among the patients requiring care? Formal justice states that equals should be treated equally and that those who are unequal should be treated differently according to their needs. This means that healthcare resources should be allocated according to needs. While it is not possible to provide equal amounts of healthcare resources to all people, it may be possible to ensure that all people have access to whatever healthcare resources are available according to individual need. The focus on need allows for ethical distribution of available resources among healthcare patients, and foregoes the distribution of these resources outside of need. Autonomy Individuals ought to be permitted personal liberty to determine their own actions according to plans that they have chosen. This means that nurses should respect persons as autonomous individuals by acknowledging their choices, which are based on their personal values and beliefs. Internal constraints (mental ability or consciousness of patient) and external constraints (hospital environment, availability of nursing resources or information available to make informed choices) to autonomy may influence the patient’s ability to be autonomous. Veracity Veracity refers to the obligation to tell the truth and not to withhold information, or lie or deceive others. Truthfulness is regarded as fundamental to the existence of trust among individuals in many cultures. In some cultures, truthfulness in healthcare presumes that the patient has a right not to know, and the leader of the family may first be informed of the patient’s condition rather than the patient. This would not be regarded as deception but rather as supportive of family relationships. Fidelity Fidelity is the obligation to remain faithful to one’s commitments. These are obligations implicit in a trusting relationship between patient and nurse, such as keeping promises and maintaining confidentiality. Confidences can be broken under certain conditions; for example, the Child Care Act 38 of 2005 requires any form of child abuse to be reported to the authorities.

Ethical decision making Identifying the values in one’s own value system through introspection and selfreflection is the first step in developing the competence to make ethical decisions. 68

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The second step is to understand the values that are important to other individuals (patients and other healthcare professionals) and the reasons why these are important. Understanding the value systems of others, and acknowledging and respecting that they are equally as valid as one’s own is essential to making ethical decisions. There are a variety of ethical decision-making models available, but there is no recipe for ethical decision making. Essentially, an ethical decision-making process must provide for an orderly approach to analysing the value dimensions involved in ethical conflicts and offer a systematic approach to implementing the decisions in patient care. Remember that ethical decision making seldom occurs in isolation and that all the relevant role players must be part of the process to ensure an acceptable outcome for all. A very broad framework to start the process is outlined in Figure 3.1, and can be fleshed out with more detail as experience grows and to suit the contexts and philosophy of the institutions where the framework will be used. While it is acknowledged that this type of framework cannot be used when decisions have to be made in an emergency, the value of using a tool like this will be in sitting down after the event and working through the framework in evaluating the outcome of the event. Exercises like this will help to shape the thought process of nurses and other healthcare practitioners so that the process is understood and becomes easier to apply when time is limited.

• • • •

What is the problem? Understand the context. What are the values involved? What do these values mean to all involved? Where does the conflict lie?

What should be done? • Develop several options to resolve the values conflict (consult widely – literature and experts). • Identify what will be the most appropriate solution. • Select an option.

Implement the selected option to resolve the ethical conflict • Implement the plan of action considering the legal-ethical framework of healthcare practitioners. • Monitor the implementation.

Figure 3.1  Broad framework for ethical decision making

Ethical responsibility of the nurse According to the International Council of Nurses (ICN), the nurse’s fundamental responsibility consists of four components: • To promote health • To prevent illness • To restore health • To alleviate suffering. In carrying out this responsibly, nurses are expected to render healthcare services to individuals, families and the community. Nurses must also co-ordinate their services with the services of other health workers. In this situation, there are many opportunities 69

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for a conflict of values, and nurses must apply their competence to the situation on a daily basis to determine what action ought to be taken.

Liability, responsibility and accountability The concepts of liability, responsibility and accountability are closely related to one another. Dictionaries assign more or less the same meanings to all three words. ‘Liability’, for example, is also regarded as responsibility and accountability. In nursing, it is important that a distinction be made between the three concepts. Nurses are, after all, liable for their acts and omissions, responsible for patient care and accountable for their actions. Liability

‘Liability’ means that a person is liable for damage that is done or caused by him or her. It is expected of a nurse to provide safe nursing care. Should it happen that he or she harms the patient as a result of careless action or a failure to act, the nurse is liable for any harm the patient may suffer. The patient may sue the nurse for damages by instituting a civil action against the nurse. If the nurse admits liability, the matter may be settled out of court. If the nurse is found guilty in a court of law, he or she is legally obliged to pay damages as determined by the court. Should the damage be done by a nurse who works for a health institution (be it a state, provincial or local authority institution or a private health service), the liability is referred to as vicarious or substitutionary liability. The health authorities employ nurses to nurse in numerous spheres, including hospital wards, clinics, district nursing services and mobile clinics. If a patient suffers any loss or injury as a result of a nurse’s conduct – whether deliberately or through ignorance or negligence – the health authority concerned is liable for damages to the patient. This does not mean, however, that the guilty nurse will go unpunished. The patient may sue the health service and the nurse concerned for damage or loss. If the health authority must pay damages as a result of a nurse’s negligence, the institution may institute a court action against the nurse in order to recover the costs. The court may also rule that both the health authority and the nurse are guilty and that each must therefore bear a portion of the damages and costs. The nurse must ensure that he or she has professional indemnity insurance. This insurance is usually included in the nurse’s membership of a national nursing association or organisation, or of a trade union. Professional indemnity insurance covers the nurse’s legal costs as well as any damages that may be awarded. Accountability

The concept ‘accountability’ has two attributes: answerability and responsibility. Nurses are answerable for their acts and for the way in which their responsibilities are fulfilled. Their accountability includes the duty to account or answer for – and justify – their actions or failure to act. Responsibility is the basis of accountability. To be accountable, nurses must be able to explain how they did or did not fulfil their responsibilities as a nurse. If a nurse harms or injures patients negligently, through incompetence, through dishonesty, or intentionally, three things can happen:

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• First, the nurse may be disciplined by the employer in terms of the disciplinary code and the code of conduct of the employer. • Second, a criminal or civil case, depending on the offence, can be brought against the nurse in the courts. Penalties that the courts can impose include fines, imprisonment, suspended sentences and admission as a patient of the state president. The Inquests Amendment Act 145 of 1992 also determines that an inquiry can be lodged into the suspected unnatural death of any patient to determine who could have contributed to the event. All persons involved in the care of the patient are called to account and to explain to the court what they did for the patient. Should it be found that the actions of the nurse have contributed to the death of the patient, the nurse will be charged with culpable homicide. If found guilty, the nurse will have a criminal record. • Third, the South African Nursing Council may take disciplinary action against the nurse. Punishment by the Council includes discharge from nursing, fines, demotion or permanent withholding of promotion in a particular service. Responsibility

‘Responsibility’ can be defined as being accountable or obliged. The nurse’s fundamental responsibility is to promote health, prevent illness, restore health and alleviate suffering. The nurse is answerable for the way in which this responsibility was carried out. This means that if a supervisor has delegated a specific task to a nurse, the nurse is responsible for carrying it out. He or she is responsible to the supervisor and to the patient for the way in which the task is performed.

Nursing as a service to humankind Nursing is viewed as part of one’s world of experience. Nurses’ philosophy influences their relationships with people, teammates, patients and students, and a healthy personal and professional approach to the way in which they perform their task in life and provide a basic indication of the quality of nurses’ work. Nurses must display sensitivity in respect of concern, care and healing. Nursing is concerned with care. In other words, nursing is concerned with people’s health needs. At any level, from the most elementary to the most highly complex and developed level, nursing has a predominantly caring role. The nurse must give meaning to the nursing role amid the wealth of scientific subjects and sciences. The nurse must learn to develop a compassionate and attentive approach to the patient and always to be within the patient’s reach. The nurse must be able to listen and to show compassion, and never lose sight of the human element in illness and healing. The more complex the scientific techniques in respect of patient care, the less personal contact there is between the patient, doctor and nurse. Furthermore, computerisation of care is bringing about a complete revolution in the patient care systems. Nurses will, to an increasing extent, have to devote attention to the human aspect of this type of mechanisation in nursing and healthcare. The nurse must not only know how these machines work but must also understand the person who is being treated by the machines, and must remember that the patient always remains a person. Because the patient is human, he or she will continually have a need for the care and support of the nurse with whom he or she can feel safe amid all the diagnostic and therapeutic 71

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equipment. The patient will always need the compassionate and understanding care of the nurse. The mechanisation of examinations and treatment cannot fully meet the patient’s health needs without a competent and concerned nurse. The nursing profession has an anthropological dimension and is therefore also a humane profession. For this reason, everything nurses do and all the information they convey should promote understanding for the person.

Duty to take care Nurses are personally responsible for their own acts, and therefore it is in their own interest to practise their profession with circumspection. Nurses must ensure that they act within the limits of the law and the codes of ethics of the nursing profession. Health legislation controlling the nursing profession gives an indication of what nurses may or may not do in nursing. Just like any other citizen of the country, nurses are also expected to obey the laws of the land. The duty to take care implies being careful and protecting. Nurses must therefore ensure that their patients are not harmed or placed in danger, and they must practise their profession carefully and attentively. Nurses are legally and ethically obliged to exercise caution in the performance of their duties. Great emphasis is placed on the nurse’s duty to take care, because nursing is concerned with people and life. For this reason, the nurse must continually be aware of medico-legal risks that may arise in medical or nursing practice or in any environment where nurses practise their professional skills. The patient is vulnerable, and often also defenceless, and for this reason the nurse has a special ethical duty to protect patients and to assist them to achieve self-assertion. Everyone has the right to expect that others will not, by their acts or omissions, harm their person, name or possessions. All the more so, the vulnerable ones (eg children, babies, senile patients, the mentally handicapped, and confused, unconscious or extremely weak patients) have the right to protection against any risks that may arise in the nursing care, treatment or environment. It is essential for nurses to be able to act with the necessary care, knowledge of nursing and experience at their specific level of training. Negligence on the part of nurses must be prevented at all times. If nurses neglect to take care and they make themselves guilty of negligence, sanctions may be imposed as punishment by the courts of both the country and the South African Nursing Council. Human rights A human right is a right (moral principle or norm) to which all people are entitled to equally and without discrimination, just by virtue of being a human being. Human rights are inalienable, which means that they are fundamental rights that are not awarded by human power and can therefore not be surrendered. This means that irrespective of where consumers of healthcare come from originally, their rights cannot be withheld, therefore a pregnant mother from another African country such as Zimbabwe may not be refused entry to maternity services in South Africa. Similarly, a patient living with HIV has a right to the provision of nursing or midwifery care. Nurses are taught to look after themselves in the healthcare situation so that nursing a patient with HIV and AIDS does not pose a risk and therefore they may not refuse to provide care for such patients. 72

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In South Africa, our human rights have been promulgated as Chapter 2 of the Constitution of the Republic of South Africa, 1996. There are various other laws that protect the rights of people in South Africa, such as the Promotion of Equality and Prevention of Unfair Discrimination Act 55 of 2003; the Protected Disclosures Act 26 of 2000, and the various labour laws.

Rights of the patient Medical progress has, to a great extent, enabled doctors to heal illnesses and prolong life. While the medical and nursing professions are becoming more advanced technologically, they are also increasingly inclined to ignore the quality of life and the rights of the patients. This tendency in the healthcare professions must be ameliorated and the patient’s rights and responsibilities recognised. Patients can lay claim to two forms of health rights: first, the right to health; and second, the right to healthcare. The right to health

The right to health concerns issues such as a safe working environment, sanitation, and pure air and water supply. In consideration of this right, it is necessary to institute protective measures for health, and legislation on smoking serves as an example of this. Because illness is caused by micro-organisms that can be spread epidemically and even pandemically, authorities are compelled to adopt countermeasures in the form of guidelines for work safety and inoculation campaigns. Further examples of this are provided by the numerous laws/ordinances and restrictions on air, noise and water pollution, as well as the compulsory inoculation of babies. The right to healthcare

The right to healthcare is heavily dependent on the availability and accessibility of health services for all citizens of the country. The state is responsible for the provision and implementation of health programmes in cities as well as in rural areas. Private hospitals and health services relieve the burden on the state to some extent in that they provide health services to those who can afford them through personal means or through membership of a medical aid scheme. The health services or health programmes to which a patient can lay claim are indicative of a comprehensive health policy. This comprehensive service encompasses the prevention of illness, the promotion of health, curative and rehabilitative care, health counselling, and support for those who are experiencing health problems. The comprehensive health programmes are implemented in numerous areas, for example clinics, hospitals, home nursing, and so on. Protection of the patient’s rights

In the highly developed technical milieu in which diagnostic examinations and treatment techniques take place, health personnel are often inclined to ignore patients’ rights. So, too, do the hospital/clinic rules and regulations contribute to the limitation of patients’ rights. For this reason it has become necessary for patients’ rights to be protected. Some hospitals constitute committees that look after the rights of patients, while others, in turn, make use of advisers whose task it is to make patients aware of their rights. The most important protector of patients’ rights certainly is and remains

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the nurse. The ethics, professional practice, methodology and standards of nursing are centred on the rights of patients. Rights of patients may include the following: • The right to full information means everything relating to available health services, rules and regulations of the hospital/clinic, as well as information with regard to the diagnosis, prognosis, treatment and nursing care plan. • The right to trained health personnel is indicative of the fact that the patient has the right to be examined and treated by a qualified medical practitioner and/or nurse. • The right to informed consent means that the patient must receive a detailed explanation of every diagnostic test, treatment, procedure, operation and their consequences before being asked to consent to them. • The patient has a right to informed refusal to grant permission for treatment/ examination. The consequences of this refusal must be explained to the patient. • The right to respect and dignity implies that, irrespective of who or what patients are, they have an inalienable right to respect for their human dignity. • The right to privacy and confidentiality refers to the patient’s right to complete secrecy, privacy and confidentiality of and about all personal information. This includes information in the medical records, on computer systems or that which has been entrusted to the nurse. • The right to examination of healthcare records means that patients are entitled to the information in the healthcare records dealing with their personal health condition. • The right to take part, or not to take part, in research is indicative of the fact that patients have the right to complete information on research, and experimental and alternative treatment that is available in order to make a free choice. • Personal rights include the right to visitors, communication (letters, telephone calls), the keeping of personal belongings, and the protection of the patient’s name, person and belongings.

While it has been highlighted that patients may refuse treatment, this does occasionally become problematic, for example in a hospital or other healthcare institution where care of patients includes, for example, bathing, eating, taking prescribed medication and ambulating. So what does the nurse do if a patient refuses to be washed? Attempts to persuade the patient, even with the assistance of the patient’s family, may not work. There are good reasons for giving a bed bath, for example, as this promotes personal hygiene and assists with prevention of infections of the skin and urinary tract, among other things. The nurse should determine any environmental issues that may be the problem, such as a male patient who may not like a female nurse or a strange woman washing him, or who may prefer his wife to do it. Patients in hospital often have very little control over what happens to them, and this may be the only area that they can control. Would it help if he could set his own schedule? Alternatively the nurse’s approach should not be to ask: ‘Would you like to wash now?’, but rather: ‘It’s time to get cleaned up. What do you need help with?’. This approach can promote independence, leaving the patient with some choice. Supportive initiatives regarding patients’ rights in South Africa include the adoption of a Patients’ Rights Charter, which sets out the principal rights of the patient. While the charter is not legally enforceable, it serves as a guideline for medical and nursing 74

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practice. No list of rights can ensure that patients will receive the type of treatment to which they are entitled. The nurse can never be exempted from the protection of patients’ rights, which are not additional to nursing practice but the true heartbeat of any decision making in nursing.

Rights of the nurse The literature on the rights of nurses reveals conflicting ideas on the subject (see also Chapter 15 in this book – ‘Caring for the needs of the nurse’). There seems to be confusion on the concepts of rights, duties and responsibilities. Many authors refer to the rights and responsibilities of nurses, implying that nurses cannot exercise their rights without accepting the corresponding duties and responsibilities. Some authors assert that nurses do not have rights, only duties. Others, in turn, refer to the rights of nurses as privileges. Still others assign special rights to the nurse, the South African Nursing Council, for example, refers to the professional rights of the nurse that are essential for safe patient care. Whether the nurse has duties, responsibilities, privileges or special rights, rights can, in fact, be assigned to the nurse. These rights are associated with responsibilities, liabilities and accountability. Nurses’ basic inalienable rights are human rights, legal rights and employees’ rights, to which can be added the professional rights that enable them to carry out their professional duties. Nurses’ rights are human rights

Like all people, the rights contained in the Constitution of the country are also nurses’ rights. Nurses have the right to freedom of speech, religion and thought, as well as the right to free participation, to satisfaction and to question things. Protection for some of these rights is included in other legislation, for example Chapter 2 of the National Health Act. Legal rights of nurses

Nurses have the right to practise nursing within the confines of a code of ethics, health and nursing legislation. In South Africa, the legal and professional rights of nurses are set out specifically in the Nursing Act 33 of 2005 and its regulations, with a broader framework provided by other related health legislation. The concept of informed consent is also applicable to nurses’ rights, for example when participating in research projects that are managed by other members of the healthcare team. Nurses are often requested to participate in activities related to the project as fieldworkers, such as distributing and collecting questionnaires or administering medication. Nurses must therefore have insight into the research project, and the potential consequences and adverse effects for patients, volunteers or colleagues participating in the study, and they must see the ethics approval for the project without which no nurse may participate. If fieldworkers were used during the study, project leaders must acknowledge their contribution in any report or article that follows the conclusion of the study. Employees’ rights of nurses

The employees’ rights of nurses are contained in the labour laws of the country, including the Labour Relations Act (LRA) 66 of 1995 and the Basic Conditions of Employment Act 75 of 1997. Some of these rights include the following: 75

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• The right to a written job description that clearly spells out the nurse’s rights and duties in the organisation • The right to remuneration • The right to information relating to pension schemes, medical aid fund, working hours, sick leave and leave regulations, benefits, notice of termination of service, dismissal and communication channels • The right to equal treatment and no discrimination in respect of gender, belief, race and sexual orientation. Professional rights of nurses

Professional rights of nurses are those rights to which they are entitled in order to practise their profession safely – in other words, to enable them to deliver quality nursing care to their patients. The South African Nursing Council highlights these professional rights on their website (see http://www.sanc.co.za/policyrights.htm) as those rights that apply in addition to the rights contained in the Constitution of the country, stating that the confirmation of these professional rights is not an end in itself, but a means of ensuring improved service to patients.

Bullying in the health sector Workplace violence in the form of bullying and lateral violence (bullying among colleagues) has become a major problem globally. It may include a wide range of behaviours ranging from verbal or physical abuse or even attacks, intimidation or harassment, as well as threats by nurses towards patients, or patients and their family towards nurses, and nurses among each other. Examples include nurses refusing to render basic nursing care such as removing a bedpan after use or issuing prescribed medication; midwives slapping patients during labour; verbal abuse by patients and their families; and union members intimidating and threatening other colleagues who do not want to participate in strike action. This creates a hostile environment for both staff and patients that has a negative influence on the safety and quality of nursing care and work satisfaction if not managed effectively and quickly. Advocacy by nurses and midwives therefore should include reporting any form of bullying of patients and colleagues. While the Protected Disclosures Act 26 of 2000 makes provision for those who ‘whistle-blow’ and report disruptive behaviour in the workplace, it remains a very difficult thing to report, particularly for the victim. Employees should be trained to recognise and deal with bullying. Organisations should institute a zero tolerance for workplace violence and appropriately address bullying through counselling and conflict-resolution strategies. Patient advocacy Patient advocacy is also known as patient mediation. Advocacy is the act of protecting or making an appeal for someone. However, advocacy by the nurse includes far more than simple intercession; it also requires that the patient be informed and supported with a view to taking the best possible decision for him- or herself. The advocacy of the nurse is basic to the nature and purpose of the nurse– patient relationship. It is a simple basis upon which the nurse–patient relationship assumes the proportions that the situation requires in any given circumstance. The

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relationship arising between a nurse and a patient can vary from one of child–parent to that of patient–adviser, friend–friend, or colleague–colleague, as well as many more relationships. It is in the nurse’s relationship with the patient that advocacy (mediation) is practised. The nurse’s advocacy is based on humanity, and encompasses or protects the patient’s rights. The nurse must therefore always ensure that the patient is treated humanely. During illness, the human rights of patients gain greater prominence. The condition of illness itself and the proportions it can assume make the patient vulnerable to dehumanisation. Just think of the difference in the degree of respect with which a conscious and an unconscious patient might be approached. You may well think: ‘What a strange comparison! Surely there is a great deal of difference between a conscious patient and an unconscious one?’ But is there really? The basic human right of respect is, after all, just as valid for the unconscious patient as it is for the conscious one. The only difference here is that the nurse must protect the unconscious patient’s right to respect, while the conscious patient commands respect to a certain extent and requires less protection. The nurse must not only understand the specific physiological changes due to the process of illness but must also understand what the illness does to the humanity of the patient. The entire being of the patient is affected, and therefore the patient is vulnerable and must be protected. At the basic level, the advocacy of the nurse is an act of love and attentiveness towards others. As the patient’s mediator, the nurse must help the patient to find meaning or purpose in living or dying. The duty of patient advocacy or patient mediation is emphasised in the South African Nursing Council’s regulation on the scope of practice of the registered or enrolled nurse.

Informed consent As long ago as 1914, it was realised that all adults in their right mind have the right to decide for themselves what may or not may be done with or to their body. This realisation led to patients in hospitals having to grant consent for treatment, examinations and operations. Even a routine procedure such as the giving of an injection requires the patient’s consent. The National Health Act 61 of 2003 prescribes that patients should have full knowledge of their health status, unless there is substantial evidence that such disclosure would not be in their best interest. It is the responsibility of the healthcare provider, usually the doctor, to obtain written, willing, informed consent for an operation from the patient, parents or legal guardian, who must have been fully informed to enable informed decision making by providing information on: a. what is to be done and why b. the possible consequences of the operation to be performed, for example that there may be disability or disfigurement, and the risks involved c. possible alternative treatment. It is important to remember that, where nurses have been authorised in terms of section 56 of the Nursing Act 33 of 2005 to diagnose conditions and prescribe treatment, these nurses are the healthcare providers responsible for the informed consent.

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When the duty of obtaining the signature of consent is delegated to the nurse, the nurse has an ethical obligation to ensure that the patient, parents or legal guardian has been informed of and understands the extent and implications of the proposed operation before signing the consent form. It is not the duty of the nurse to attempt explanations for the planned treatment. The consent form must be accurately completed. Mention must be made of the correct site or side (where applicable) of the operation. The consent form is signed: a. wherever and whenever possible or on admission of the patient; or b. when it has been confirmed that the patient is due for operation; or c. on the day of operation before any premedication is given and in the presence of two witnesses (usually a registered nurse and one other nurse) who must also sign the document. Their signatures then confirm that it was the patient who signed the form and that the patient understood what would be done during surgery. If, at the time of signing, the patient expresses any doubt or concern about the operation or its extent, or about the anaesthetist or the doctor who will perform the operation, the patient should be referred to the surgeon before signing the consent.

Period of validity of consent Consent is valid for one procedure and for one admission. A separate consent form should be signed for each separate operation or treatment performed. One consent form is usually enough for a patient undergoing certain treatments or tests for the same condition, such as a course of deep radiation therapy. A new consent form becomes necessary if the operation or treatment has been postponed and there has been a break in hospitalisation or if a doctor cancels an operation or treatment for which the patient has given consent and then changes his or her mind in favour of other modes of treatment. Giving consent • In the case of an unconscious patient, relatives may give consent. The relationship should be stated. Section 7 of the National Health Act 61 of 2003 provides detailed guidance on the provision of consent in this situation – the spouse, partner, parent, grandparent, adult child, brother or sister of the patient, in this order, may give consent in this situation. • Any person over the age of 12 years may sign for a procedure or any medical treatment on him- or herself. A pregnant woman of any age may give consent for a termination of pregnancy if such consent is given in terms of section 129 of the Children’s Act 38 of 2005. • Any person over the age of 12 years may give consent for an operation, provided that: a. the child is of sufficient maturity and has the mental capacity to understand the benefits, risks, social and other implications of the surgical operation; and b. the child is duly assisted by his or her parent or guardian.

The parent or guardian gives the necessary consent in the case of: a. patients under the age of 12 years; or

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b. patients over that age but who are of insufficient maturity or are unable to understand the benefits, risks and social implications of the operation.

Procedure or treatment The Children’s Act goes on to provide detailed guidance on consent in a variety of situations under which consent for children should be obtained. The Act stipulates that telephonic consent should be used only as a last resort. The person receiving telephonic consent for a procedure must have a witness. The required procedure for arranging telephonic consent is outlined below: 1. The name, relationship, address and telephone number of the person giving consent must be written on the patient’s consent form. 2. The identity of the person giving consent should be obtained. This information must then be confirmed by feeding it back to the person giving consent, while the witness checks that the information corresponds with what has been written down. 3. Both the person receiving the consent and the witness must sign their names legibly and in full, and indicate their rank. 4. The date and the time at which consent was received must be recorded. 5. The words ‘telephonic consent’ must be written on the form. Written confirmation of the consent must be obtained and submitted as soon as possible thereafter.

Ethical dilemmas A dilemma may be described as a difficult choice that must be made between two equally unpleasant alternatives. A choice between the greatest good deed and a small sin is merely a problem to be solved, and not a very difficult one at that. A dilemma, however, encompasses a great deal more than merely the solution of a problem. In the case of a true dilemma, all solutions will have potentially unfavourable consequences. For the nurse, an ethical dilemma is a very difficult choice between two equally sensitive and unpleasant alternatives. Whatever the nurse’s choice is, there will be negative consequences. For example, a nurse in the emergency section who is on duty alone at lunchtime is confronted with a dilemma if two patients with equally serious arterial bleeding arrive simultaneously. The nurse cannot wait for help and must make a choice immediately in relation to which patient will be treated first and why, bearing in mind that there is a possibility of the untreated patient dying as a result of this choice. That is a choice between two equally undesirable circumstances.

Sanctity of life versus quality of life The most difficult ethical dilemma a nurse can be faced with is the question of the sanctity of life versus the quality of life. The concept of sanctity of life implies that life is precious and that it must be protected and preserved at all times. A comprehensive health service, modelled on the prevention of illness, the promotion of health, curative and rehabilitative care and health counselling, is a sign of how important human life is regarded to be. Both the medical and nursing professions are intent on saving or prolonging a life. There is no fault to be found with this principle. The problem arises, however, when the quality 79

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of life is affected, as, for example, in the case of premature or severely deformed babies, terminally ill cancer patients, chronically ill elderly persons and serious trauma resulting in brain damage. Can these types of patient still lead (or expect to lead) a normal life? In these cases, a choice is demanded of medical and nursing science as to whether a life should be saved or treatment withheld. This is when the preciousness of life is weighed against the quality of life. The dilemma, however, remains that in spite of human assessment of a patient’s inability to recover full capacity, it has happened that a patient has woken from what seemed to be hopelessly comatose state, and has gone on to live a full life. The age and prognosis of the patient are important aspects to be considered. Nurses in intensive care units often have to make decisions or recommendations regarding patients who have to be transferred to general wards in order to make beds available for others. Often an older patient who has a shorter life expectancy must make way for a younger one. However, we may rightly question whether the elderly patient’s life is less precious than the young person’s. There is no easy answer. A further dilemma regarding the sanctity of life versus the quality of life is the decision of whether or not to resuscitate a patient or, where the patient is dependent on life-support machines, whether or not to switch them off. In these situations, urgent consultation between the doctor, the nurse and the family is essential. A decision must be made jointly about whether or not there should be treatment. If it is decided to stop the therapeutic (medical) treatment, this does not mean that the nursing of the patient stops. The nurse is still responsible for the protection and care of the patient and for providing him or her with the necessities of life (eg food and water) in line with Henderson’s model of nursing (see Chapter 1 page 13). Euthanasia (the painless ending of the life of a patient suffering from an incurable and painful disease or in an irreversible coma) and assisted suicide (suicide of a patient suffering from an incurable disease, effected by the taking of lethal drugs provided by a doctor for this purpose) are not legalised in South Africa, and practitioners who participate in such activities may be charged with murder. The principle of sanctity of life (ie that life is as sacred under all circumstances) can come into conflict with the principle of quality of life (ie that life should be effective, respectable and full). Both principles place demands on nurses; neither is flawless in all instances, and both give rise to further questions.

Codes of ethics in nursing A code may be defined as a system of principles and moral rules. A professional code may refer to the values and norms of the majority of members of a profession. A professional code is a set of moral principles or rules that regulate the professional conduct of a profession. A code of ethics in nursing may be viewed as a statement about nursing and the objectives of nursing. In nursing practice, nurses are to follow specific moral guidelines that take patients’ interests and rights into account. The code of ethics holds the nurse responsible for acceptable standards of nursing care. The advantages of a professional code of ethics are that it reassures the public, provides guidelines for the regulation of the profession and discipline of its members, and affords a framework within which

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nurses can formulate their decisions. For the nurse, a professional code of ethics provides guidelines for practice. Following are codes of ethics that are of importance to the South African nurse.

The Florence Nightingale Pledge Florence Nightingale had nothing to do with framing the Florence Nightingale Pledge. A committee headed by Mrs LE Gretter drew it up in 1893. I solemnly pledge myself before God and in the presence of this assembly: • To pass my life in purity and to practise my profession faithfully; • I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug; • I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling; • With loyalty will I endeavour to aid the physician in his work, and devote myself to the welfare of those committed to my care.

International Council for Nurses (ICN) Code of Ethics for Nurses The International Council of Nurses (ICN) first developed and adopted a code ethic for nurses in 1953 following which it was revised to accommodate changing societal needs with the latest revision in 2012. The elements of the 2005 revision of the ICN Code are given here, and the full document contains a chart to assist nurses to translate these standards into action (find the full document at http://www.icn.ch/icncode.pdf). 1.  Nurses and people

The nurse’s primary professional responsibility is to people requiring nursing care. • In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. • The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment. • The nurse holds in confidence personal information and uses judgement in sharing this information. • The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. • The nurse advocates for equity and social justice in resource allocation, access to health care, and other social and economic services. • The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness and integrity. 2.  Nurses and practice

• The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning.

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• The nurse maintains a standard of personal health such that the ability to provide care is not compromised. • The nurse uses judgement regarding individual competence when accepting and delegating responsibility. • The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance its image and public confidence. • The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people. • The nurse strives to foster and maintain a practice culture promoting ethical behaviour and open dialogue. 3.  Nurses and the profession

• The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. • The nurse is active in developing a core of research-based professional knowledge that supports evidence-based practice. • The nurse is active in developing and sustaining a core of professional values. • The nurse, acting through the professional organisation, participates in creating and maintaining safe, equitable social and economic working conditions in nursing. • The nurse practises to sustain and protect the natural environment, and is aware of its consequences on health. • The nurse contributes to an ethical organisational environment, and challenges unethical practices and settings. 4.  Nurses and co-workers

• The nurse sustains a collaborative and respectful relationship with co-workers in nursing and other fields. • The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person. • The nurse takes appropriate action to support and guide co-workers to advance ethical conduct.

The South African Nurses’ Code of Service The South African Code has been amended by many of the nursing education institutions and basically consists of the following: I solemnly pledge myself to the service of humanity and will endeavour to practise my profession with conscience and with dignity. • I will maintain by all the means in my power the honour and the noble traditions of my profession. • The total health of my patients will be my first consideration. • I will hold in confidence all personal matters coming to my knowledge. • I will not permit considerations of religion, nationality, race or social standing to intervene between my duty and my patient. • I will maintain the utmost respect for human life. • I make these promises solemnly, freely and upon my honour.

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The meaning of the Lamp in the pledge of service These concepts were developed by Miss BG Alexander RRC and the statement prepared by Charlotte Searle in 1945: • The Lamp in your hand is the symbol of those who keep vigil over the sick. • It is the symbol of the philosophy of the nursing profession that those who nurse should be a light unto others. • It indicates that you are prepared to develop your profession and to practise it in the light of the sciences which are the building blocks of medical and nursing sciences. • It confirms that you are prepared to carry out your professional acts in accordance with the legal and ethical codes of your profession and that you are prepared to care for man in his uniqueness with knowledge and compassion. • It is the symbol that indicates that you are prepared to be the following for those who need your help: –– The eyes of the blind who are sick; –– The power of movement for those who cannot move; –– The hands of those who do not have the strength to care for themselves; –– The comforter of those who are alone or grieve; –– The nourisher of those who cannot eat; –– The protector of those who are helpless and those who are vulnerable; –– The mind of those who are unconscious; –– The one who has to ward off the hazards threatening the sick; –– The intermediary between the doctor, other members of the health team and the patient; –– The advocate of those who have health problems. • It confirms that you as a professional nurse are prepared to submit to the discipline for your profession. • It serves as proof that you are prepared to serve as a role model of your profession. I give you the reveille of nursing: ‘ Let the oil of knowledge and of love always ensure that your lamp burns brightly.’

Conclusion Nurses and midwives are core members of a healthcare team that have a shared set of values informing their shared interest in the wellbeing of their patients. This chapter provided an overview of the elements of the professional-ethical framework informing nursing practice, which are essential for the provision of safe and quality care to patients. Nurses and midwives of all categories are accountable for their actions and omissions, which means that they are expected to always be able to justify their decisions and actions.

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Suggested activities for students Activity 3.1 To clarify this intense content thus far, students should be arranged in groups of five where, in each group, individual students should indicate in writing a personal philosophy as a point of departure for discussion with colleagues.

Activity 3.2 Summarise the professional rights of nurses found on the website of the South African Nursing Council (http://www.sanc.co.za/policyrights.htm). Discuss in groups how it applies to clinical nursing and midwifery practice.

Activity 3.3 A mentally confused patient is found wandering about, away from his ward. He has missed his scheduled treatment because he was not in the ward at the time. • Each student is to write a statement about the patient’s situation that would indicate that the charge nurse is to blame. The statement must indicate aspects relating to various philosophical schools of thought as well as of those relating to liability, accountability and responsibility which have been overlooked from the charge nurse’s point of view.

Activity 3.4 A young man has been diagnosed with a sexually transmitted disease. He admits to having several sexual partners, one of whom is your cousin’s daughter who is at school in Grade 12. To your knowledge, the man should inform his sexual partners to come for treatment. The man refuses to do this. • In your class groups, debate, discuss and role-play how this situation could be handled, bearing in mind the ethical and legal issues, patient’s rights and the nurse’s advocacy role.

Activity 3.5 A 17-year-old schoolgirl is brought to the termination of pregnancy (TOP) clinic by her parents. After discussion with the parents, it becomes clear that the desire to terminate the pregnancy is solely that of the parents and not the girl. Irrespective of this, the appointment for the procedure is set. The girl fails to report at the clinic on the day of the appointment. Two days later the parents phone the clinic to find out if the girl is still at the clinic and the answer is: ‘No, she never arrived on the set date’. • Analyse the issues that are involved in this case. What are the ethical and legal implications as well as human rights that need your attention in this case? • How can this case be handled, bearing in mind professional behaviour and personal and societal norms and values?

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chapter

4

Information management

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate an understanding of the legislation governing information management in patient care. • Identify the standards for information management systems in healthcare. • Demonstrate the competence to collect patient’s information. • Identify and discuss the role of the nurse in managing patient information. • Competently perform manual record keeping. • Demonstrate an understanding and competence to perform electronic record keeping.

Key concepts and terminology Data: Discrete entities that describe or measure something without interpreting it. Information: A relationship between data, consisting of interpreted, organised or structured data. Information management: The constructive handling of information in the interest of effective management of the business of the organisation, in particular quality decision making in healthcare delivery to ensure that the right information is available at the right place at the right time. Information systems: Either manual or automated. Automated systems are necessary to manage large volumes of data. Computer hardware and software are used to process data into information needed to examine patterns and trends, to solve problems and to answer questions. Data should be collected at the point of care, and information made available to healthcare providers when and where it is needed. This is accomplished by a network of computers within and between institutions. Such a network may consist of several hospitals, clinics and other health-related services. Such information is stored in a central data repository where it is accessible to authorised users located anywhere in the world. Manual systems are used for paper-based reports. Knowledge: Information that has been combined or synthesised so that interrelationships and patterns with their implications are identified. Nursing informatics: The integration of nursing, its information and information management with information processing and communication technology to support nursing and general healthcare. ➙

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Social media: Online communication tools used for participation in social networking that allow people to create, share or exchange information, ideas, pictures and videos with virtual communities and networks.

Prerequisite knowledge The nurse should have knowledge of the following: • Note taking • The general taking of minutes.

Medico-legal considerations Legislation obliges all healthcare providers to keep accurate and complete records, in particular the following: • The Constitution of the RSA (1996) in Chapter 2, on the Bill of Rights, determines that all persons have a right to an environment that is not harmful to their health or wellbeing, and to protection of their dignity, privacy and property. This can only be achieved and maintained by good record keeping. • The National Health Act 61 of 2003 refers to the responsibility of healthcare establishments and the staff of those establishments to keep, maintain and protect patient and other records of the institution in a confidential manner. The National Health Act 61 of 2003 also determines that information on patients is confidential and can be disclosed only under specific conditions. • This is supported by the Promotion of Access to Information Act 2 of 2000. • The Nursing Act 33 of 2005 and its regulations specifically prescribe the responsibility of nurses to keep and maintain clear and accurate records on patient care. • The National Archives of South Africa Act 43 of 1996 prescribes the storage of documents. • The Electronic Communications and Transactions (ECT) Act 25 of 2002 applies to personal information that has been obtained through electronic transactions. It compels those who request personal information from patients to get express written permission following disclosure in writing of the specific purpose for which this information is requested. This information may not be disclosed to a third party unless authorised for this purpose. • The Consumer Protection Act 68 of 2008 protects the consumer, including patients, against exploitation and harm. This Act protects consumer-based rights, namely the right to: –– equality –– choose services and providers –– privacy and confidentiality –– disclosure of information –– fair and responsible marketing –– fair and reasonable contract terms/conditions –– value, quality and safe goods (Melville 2011). ➙

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• Complete and accurate records in healthcare are: –– essential to maintain good communication between members of the multidisciplinary team and thus prevent unnecessary mistakes –– the only tools that healthcare practitioners have, to provide proof that healthcare has been provided to the patient. Such records are the best insurance against any claims that patients have, and therefore nurses have an obligation to make sure that records are complete, accurate and up to date.

Key ethical considerations Confidentiality of the data collected remains the most important aspect in the management of patient information. The following ethical principles must be adhered to: • Beneficence and non-maleficence: Create comprehensive records that are accessible and understandable by all other practitioners. • Justice: Create records without prejudice and judgement with regard to individuals’ information or their condition. • Autonomy: Each practitioner must record his or her own activities and take responsibility for the actions taken. • Veracity: Record truthfully and honestly. Altruism, an unselfish concern for others, informs veracity where practitioners will report honestly and not try to protect themselves with fraudulent reporting. • Fidelity: Each practitioner must honour his or her commitment to keep patients’ information confidential.

Essential health literacy Health education is personalised for patients according to their specific health problems and health status. Good records are essential to customise any education and advice that is provided to patients.

Nursing implications • Nurses must always familiarise themselves with the recording requirements and systems of new institutions or units where they are placed for clinical learning experiences. • Remember, in the legal system, if something has not been recorded it is regarded as not having been done. Nurses should make time to record all the tasks that they have performed before leaving the clinical situation.

Introduction Healthcare providers need reliable and accurate patient information at the point of care to ensure the best treatment and care for every patient. Information management 87

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comprises the keeping of comprehensive records, management of information that has been collected and the use of communication technology because these aspects are an integral part of healthcare and nursing practice. A well-designed information management system promotes finding and sharing of information easily and is essential for safe patient care. It organises content in a logical way, and makes it easy to standardise content creation and presentation across the institution, thus supporting knowledge management. It helps the organisation to meet its legal responsibilities. Within this bigger information management system, it is important to include nursing information. In addition, nursing care and accurate and complete information are critical components of effective decision making and high-quality nursing practice. The information and knowledge gained through nursing informatics can contribute to increased awareness and understanding of nursing and healthcare issues. Informatics can make nursing practice visible in healthcare datasets, thus empowering nurses with information to influence policy. Information management systems can be both manual and electronic. Generally, large volumes of information and data are managed in electronic databases.

Standards for an information management system Staff must know how to effectively use the system and maintain security measures. Smartcards or passwords to access information systems must not be shared. Similarly, staff should not leave systems open to access when they have finished using them. Irrespective of the information management system that is used in an institution, there are common standards that apply (Muller, Bezuidenhout & Jooste 2011): • There is a ‘fit-for purpose’ management information system in accordance with the internal and external information management and reporting needs of the institution. • There is a functional manager who is responsible for the management information system. • The information management system is compliant with the professional-ethical and legal requirements. • There are policies and procedures to ensure confidentiality, security and integrity of data and information with reference to at least the following: control of access, user’s obligation to keep data and information confidential, and disciplinary measures in case of transgression of policy. • There is a process to aggregate the data. • The aggregation of data is used to support decision making at operational, middle management and corporate management levels. • The management information system is compliant with the short- and long-term needs for internal and external reporting in accordance with legal and quality requirements. • The storing and retrieval of data are in accordance with legal requirements. • There is a maintenance and replacement system in place to ensure business continuity.

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Common problems identified with record keeping include the following: • Unclear or incomplete records, such as: ‘Had a restful night’, a statement which is meaningless and does not provide any information on what the patient’s condition is or what happened during the nightshift • Using too much jargon, which makes notes difficult to understand • Inaccuracy on records, such as spelling mistakes, misspelling of names, wrong diagnosis, failure to transfer patient details on continuing reports, wrong information on identity bands, etc • Fraudulently recording information, for example reporting that a patient had a dressing changed when this never happened, or charting blood pressures never measured • Omissions in documenting information: –– Action taken when problems are identified, for example when a recording such as: ‘Patient is suffering increasing pain’ is not followed by a recording that pain medication was administered –– Telephone calls made to doctors, patient’s family or others –– Conversations with healthcare team members or family members and patients.

Managing patient information Patient records are only one type of record that healthcare institutions have to create, maintain and store. While all other records can be related to patient care, this chapter will consider only some aspects of patient information and its management, starting with some consideration of the importance of supporting information to create effective patient information tools.

Supporting information An important element of the management of patient information is that patient records should provide sufficient and appropriate information to inform decision making related to patient care. This often requires nurses to access information to assist with understanding the patient’s condition. While reference materials are often available in the unit for nurses, smart phone availability has significantly improved the ability of nurses to access new information quickly. Great care should be taken with the information available on the Internet and only information from trusted and credible resources should be consulted. Evidence-based practice

Another reason for nurses to access updated information, in particular research articles, to inform decision making and patient care is the increasing prominence of the importance of evidence-based practice. Evidence-based practice, related to medicine or nursing, refers to clinical decisions being made on the basis of the best clinical research evidence currently available applied to the specific needs of the patient which tend to maximise the effect of clinical judgement.

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Cellphone use

Cellphone use to access information in the workplace has to be applied with great caution. The use of electronic devices has significantly increased in all spheres of life, including communication with cellphones. There has been much debate about whether cellphone signals influence or disrupt medical equipment in healthcare settings, and the use of cellphones is usually prohibited in hospitals. Interference by cellphone signals depends on the intensity and the frequency of the signal, and the degree to which equipment in the vicinity of such devices is shielded. Modern devices, both electronic equipment and cellphones, are manufactured to address these elements to make them less sensitive to cause or respond to interferences. Rules for cellphone use in clinical settings

Having indicated the role that cellphones can play in assisting with understanding and interpreting patient information, it is also recognised that they can be very disruptive in the units where nursing and healthcare are provided. This requires some rules related to cellphone use for everyone in the workplace. 1. Common courtesy requires us to respect those in our vicinity, so the following rules are recommended: • Leave cellphones at home or switch them off at work so that calls go to voicemail. • Respect areas that are indicated as call free zones such as theatres and high technology units where electronic equipment is used. • Do not play games, text, read or post updates when on duty. • When in a meeting, use the cellphone only to check on the calendar and not for anything else – remain engaged in the meeting. • Refrain from putting a cellphone on vibrate as this can also be disturbing to others and distract its owner. 2. Never ever multitask by taking calls when administering care to patients as this creates a break in concentration which increases risk for adverse events. 3. Take only calls that are urgent, and step away to do so. In such cases, do not: • yell • take calls in enclosed spaces such as a lift or restroom • put the cellphone on speaker. 4. No pictures may be taken with a cellphone of patients and their related information – not even for the purposes of assignments or class discussion. It goes without saying that no such photos may ever be posted on Facebook, Twitter or any similar social media platforms. The only time that pictures are allowed to be taken is when research ethics approval has been obtained, or for specific clinical reasons, such as when wound-care practitioners need to record the progress of patients’ healing. 5. Much has been said about the possible risk of infection through telephone instruments that are used by many, but cellphones may be even worse even though they are usually used by only one person. Cellphones are carried in people’s hands and are often put down randomly, for example on different patients’ beds, which can pose a health hazard.

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The need to generate and maintain patient information When a patient is admitted to the hospital or other healthcare facility, all the administrative and clinical data and reports that are collected about this patient must be recorded and kept in a file. This information then becomes the basis on which management of the patient is planned and executed by the relevant healthcare practitioners. This information is also used as evidence at disciplinary hearings, professional conduct hearings at the Council, inquests and criminal proceedings. This again emphasises the importance of using language that can be understood and interpreted by all. Over time and with experience and expertise, nurses can look for patterns in the data and information that have been collected. This would include looking for similarities and differences in response to the disease and therapies for specific patients and over patient populations. Remember: • Different individuals collect and record data in the patient’s file. The data should be labelled to give meaning. Depending on the information recorded, the label may relate to a measure of a variable such as the blood pressure (eg 130/80 mmHg) or a narrative which clearly qualifies the activity with the time and date it was undertaken and a signature at all times (eg ‘at 10h30 Mrs Bell complained of a headache. The sister in charge was informed and she …’). • Without context, data may have no meaning – without the ‘mmHg’, for example, the blood pressure value may not mean anything for someone else who does not know the records used in the institution. Adding ‘mmHg’ to the figures starts to organise and structure the data obtained. • This blood pressure can immediately be evaluated by comparing it to the normal values for people in this age range – the age would be data on the patient’s file too. The blood pressure reading may be compared with the previous reading on the same day or other days to assess response to treatment. This starts to combine and synthesise data to make the first interpretations about this patient’s health status, creating the first steps to information that creates a knowledge base on the patient. • And importantly, remember that patient files are also evidence, so care should be taken about how and what is reported.

Legal alert! Records are legal documents (see ‘Principles of good record keeping’ on page 94). Other reasons why records are kept in addition to planning nursing and healthcare are the following: • To ensure continuity of care because nursing is a 24-hour service and no nurse works 24 hours in a shift. • To enable co-ordination of care; for example, if a patient is going for surgery there may be a need to take blood for electrolytes and a blood cell count, while the nurse may need to prepare the skin and do other procedures. Whether these have been done or not can only be ascertained through the record in the patient’s file. ➙

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• To provide the opportunity to evaluate the quality and/or the cost of care provided to the patient. • To be used as a training or research tool in the healthcare arena. • To advocate for the patient long after discharge – records will indicate if treatment was administered and care was provided, and what these entailed.

Confidentiality and access to records The laws protecting confidentiality of patient information have been listed earlier. The person in charge of the healthcare institution or the clinical unit must put measures in place to ensure that these records are kept confidential, including when they are stored after discharge of the patient. Patient records are confidential records that may be legitimately accessed only by the following persons: • The patient • Members of the multidisciplinary healthcare team responsible for the patient • Lecturers and students for study or teaching purposes; or for research with the authorisation of the patient, head of the health establishment concerned and the relevant health research ethics committee. This is one of the reasons why there is an accreditation and approval process before students are allowed to go into the clinical situation for experiential learning. Patient records can be accessed only with permission from the patient, and/or parents or guardians of children and debilitated and incapacitated patients, or with a court order. Should the patient or parents not be able to provide such permission, section 7 of the National Health Act 61 of 2003 and section 129 of the Children’s Act 38 of 2005 provide clear guidelines on how permission should be sought. Furthermore, healthcare practitioners may not keep photographs of any person or their family that are not clinically relevant. In particular, such images cannot be posted on social media platforms. Images may not be used in any publications without the required permission. Practitioners are accountable for keeping information confidential, which can be promoted by the following: • Collecting and using data only for the purpose for which it was given • Obtaining consent to share information, and ensuring that patients know with whom it is to be shared • Disclosing personal information only to people who have a legitimate need for it • Ensuring all records are kept according to the standards of accuracy • Never leaving confidential documents unattended • Keeping confidential, personal and identifiable information in locked storage • With regard to electronic records, logging out of computers following use and not sharing passwords.

Ten key electronic health record lessons for nurses and nurse administrators: 1. Make sure your current infrastructure can support robust, compatible electronic health records.

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2. Involve all role players with nurses and nurse informaticists as main partners in design and implementation of electronic records. 3. Strike a balance on customisation to ensure that the system developed does not become cumbersome. 4. Prepare the staff, but anticipate resistance – the organisation must be ready for this. 5. Expect productivity losses in the initial weeks. Make additional staff available over and above the trainers during the period that staff learns how to use the new system while caring for patients. 6. Design a system focused on using data to improve care. 7. Understand and prepare for the impact on patient interactions that include time limits, lack of eye contact with the patient and focusing on the screen, and a robotic effect on clinical judgement. 8. Strive for interoperability across settings with tighter clinical integration across practice settings. 9. Guard against information overload. 10. Measure results and have a process in place for nonstop change. Source: Swartz (2012)

The role of the nurse Nurses do not collect data just for the sake of filling out forms or punching data into a computer. There must be a reason for getting that information. For example, fourhourly blood pressure or temperature charts will not be kept for patients in an old-age home. Should an aged person be on blood pressure medication, for example, the staff would check his or her blood pressure weekly or monthly if it is stable. However, for a person who has just come out of surgery, temperature, pulse and blood pressure checks are done every 15–30 minutes. As the patient stabilises, the observations and subsequent recordings are done within longer time intervals. If responsible for this task, nurses must do the following: • Accurately observe the patient. This means that nurses must use all senses when doing these observations together with the tools at their disposal. Linking to the previous example of monitoring blood pressure every four hours, nurses must be able to use electronic as well as manual baumanometers and stethoscopes effectively to measure blood pressure. If, when using a stethoscope, the pulsating sounds to determine blood pressure are inaudible, the nurse should ask for help, and should not just write up something similar to the previous recording. It may be that the patient’s blood pressure has dropped so low that it is not measurable. This is when the nurse can use other senses to check if the patient is awake and responsive, and able to answer questions. If there is a response, the patient’s blood pressure must be measurable. (For the monitoring of blood pressure, refer to Chapter 10, Juta’s Manual of Nursing, Volume 2, and Chapter 3 for an example of a blood pressure chart.) • Analyse, document or capture, report and accurately utilise all relevant information on the situation in order to facilitate continuity of care. Document information in a manner that will be meaningful to the improvement of quality care. For example, temperature is recorded on a chart with dots and connecting lines, which gives 93

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•

• • •

a clear indication of the patient’s status over a period of time. (For temperature taking, refer to Chapter 10 in Juta’s Manual of Nursing, Volume 2 and Chapter 3 for an example of a temperature chart.) In an intensive care unit, all the patient’s data are recorded on a flow chart so that a clear picture of the patient’s condition at any time during the day is available at a glance. Record or capture data on the interventions undertaken and the assessment of intervention outcomes. Analyse the outcome data accordingly based on the findings. Records must support decisions to drive new plans of care. Report on the consolidated information based on the analysis of outcome data verbally and/or in writing. If there is a difference in the blood pressure from the previous recording, this should be reported to the unit manager immediately. The overall report on the patient’s condition written by the unit manager is based on all the observations done during the day, and is usually in the form of a narrative.

Manual record keeping The majority of healthcare institutions still use manual or paper-based records. As records for patients who stay in hospital for a long time or who are chronically ill with frequent visits the healthcare institution can become big and cumbersome, they are often put on microfilm to make storage and safe keeping easier. Principles of good record keeping Different institutions usually use differently formatted records. The principles of good record keeping include the following: • Legal requirements: –– Maintain the required format of the institution. –– Ensure that all patients’ records bear the patient’s name and hospital registration number or personal ID number. –– Use legible writing in a permanent form – that is, in black ink that will provide clear photocopies or scans when required. –– Include the date, time and a signature and designation on all notes made – if signatures are not legible, include a sheet with printed names and sample signatures of all staff who work with the patient in the record (for electronic systems, different identifiers are created and used to identify the practitioners making the recording). –– Do not use abbreviations unless these are the universally accepted ones. –– Do not alter or destroy documents without being authorised to do so. –– Do not use coded expressions of sarcasm or humorous abbreviations to describe patients. –– Do not leave open spaces in the progress report of a patient. –– Do not erase mistakes or use Tippex on the paper records. Draw a clean line through the statement or item you wish to disregard, and sign and indicate ‘incorrect’ over the cancellation. Also indicate the date and time of this activity so that all can see what was written underneath.

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• Records must be complete – there should be no gaps in the information on the documents that were generated during the care of patients. • Recorded information should be written in such a way that the meaning is clear. • Records should identify any risks or problems that have arisen, and indicate what action was taken to deal with them. • Records must be an effective documentation of the reality in a chronological order and with accurate stipulations, leaving no chance for misinterpretation. If in doubt about what was written, such as in a prescription for medication, be sure to verify the prescription before administering any treatment. There is no excuse for not checking in such cases. • Record events and actions taken as soon as possible to ensure an accurate record on the condition of the patient.

Incident reports Despite the most careful precautions, medico-legal accidents do occur, not necessarily due to any negligence on the part of the nursing staff. For example, a patient may get out of bed in defiance of all the requests by nursing staff and without giving any sign that he or she needs to be restrained in any way, and the result may be a fall. In all cases of accidents, all the staff responsible for the care of the patient at the time of the accident/incident must write incident reports. This will include nurses who were assigned to the patient, who were working with the patient, or who saw or heard the accident. The nurse in charge of the department at the time will also write a report. In instances where the patient was not assigned to anyone, the nurse in charge has to write the report. An account of the incident must be recorded in the patient’s nursing progress record. The purpose of an incident report

Incident reports should not be automatically regarded as a black mark against the nursing staff who write them. They are simply the following: • Legal records of an incident that occurred in a healthcare institution • Intended to protect the nursing staff against unjust accusation • Intended to protect the patient in the case of negligence on the part of the staff • Used in the evaluation of nursing care to ensure the safe care of all patients. Writing an incident report

The form to be used and the number of copies to be written will depend on the policy of the healthcare institution. The standard principle is that there must be at least three copies for the institutional files, the ward incidents record book and the patient’s file. The report should be written at the first opportunity after the incident so that details are not forgotten or blurred. Ink should be used, not a pencil, because pencilled writing can be erased. The patient should be identified with his or her full name, hospital ID, bed number and details, and nature of the ward or clinical area. Other details that should be included are the patient’s diagnosis; the date, time and place of the incident; the condition of the patient immediately prior to the incident and immediately after it; and a record of the observation made from that time.

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Only the facts should be described. Descriptive adjectives should be kept to a minimum, and the nurse should not give a personal opinion or state anything that may seem to allocate blame. For example, instead of: ‘Mrs Naidoo is very difficult and would not listen when I told her to stay in bed; it is her fault that she fell, and not the nurse’s’, the nurse should compose a very much more objective statement that gives only the facts of the incident: ‘I heard a crash and when I ran into the ward, Mrs Naidoo was on the floor. She has been nursed at bed rest.’ Note the following points on the description and recording of facts: • Write the events in the sequence in which they occurred. • Use the correct technical terms (eg a urinal, not a ‘bottle’). • Identify any witnesses (eg ‘Nurse Fourie witnessed the incident’). • Identify any medication given before the incident (eg a sleeping tablet). • Identify any equipment involved (eg a bedside locker with wheels). • Record vital observations taken immediately after the incident. • Record the time the incident was reported to the medical officer, as well as the doctor’s name. • Record the medical officer’s response and orders. If the patient was seriously hurt, also record the time the medical officer arrived in response to your call. • Sign the report legibly with your correct designation. • Attach the medical officer’s report to the incident report.

Electronic management of patient information Hospitals are increasingly moving to ‘paperless’ systems. Although computerisation and other technologies have improved communication efficiency, the principles for good management of information remain the same, whether electronic or manual paperdriven systems are used. It is imperative that hospital information systems must benefit staff and patients, must make sense to those who use them, and must not increase the workload. The information technology required to manage information electronically includes computer hardware and software, telecommunications and databases. The benefits of electronic patient records • The benefit of electronic records is that up-to-date, accurate information is available to all members of the healthcare team as soon as it has been captured. • They are an important factor for safe, high-quality patient-centred care. Practitioners not in the clinical unit all day can actually access the information from a remote position to evaluate how the patient is responding to treatment and whether there is a need for treatment to be revised. A written prescription can then be sent through to the staff in the clinical unit. • There are no papers that can fall out and get lost. • They can be cost effective if paper systems are not used concurrently. • Information can be stored for a long time, and storage does not require a lot of space.

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Challenges of electronic records and databases • Support and training for staff to work with electronic records and databases must be provided. All nurses therefore need informatics competencies. These competencies encompass computer skills, informatics knowledge and information skills, therefore nurses need to know how to identify, collect, record, analyse and interpret pertinent patient and nursing data and information; they need to know how to use computer applications and manage the privacy, confidentiality and security of data. The training may be long and expensive as well. • Where electronic records will be used and information captured, there should be enough computers available for staff to have easy access. Expecting nurses to write observations on a piece of paper or on their hands to go and capture it on a central computer at the nurses’ station is not acceptable, and will lead to mistakes or incidents where data are not captured on the system. The sourcing of computers and the relevant software may be expensive. • Systems must be maintained and require specialised assistance to do so. • Back-up of the data is essential, and at least one copy of the data back-up must be safely stored in an off-site venue. Such copies must be protected from access by unauthorised persons. Criteria for electronic patient records

Electronic health records for patients must: • be accessible at the place and time where they are needed (if power failures make it impossible to access information, the system will not be conducive to quality health and nursing care) • respect and protect the privacy of patient information • include clinical data from all disciplines • include the establishment and integration of unique identifiers to capture nursing care. The system must be designed in collaboration with professional nurses to ensure that clinical data are captured in a standardised way that reflects the practice and impact of nursing care interventions and outcomes. Successful implementation of information systems therefore requires the following to maintain the quality of nursing data and information in a documentation system: • There must be sufficient material and human resources to fully implement and maintain the system. • Staff must be trained to use the equipment and programmes effectively. Nurses need skills in quantifying data and aggregating information to gain knowledge of individual patients as well as patient populations. Nurse managers require these skills too to support staff and to assess these competencies in staff. Opportunities for staff to acquire these skills must be created by management. • Well-designed systems that support the provision of care within the culture of an organisation and are specific to care providers must be created. Other benefits of electronic records include the following: • Access to government services to complete and submit forms electronically for social support or other purposes 97

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• Global access to information and research to assist with informing practitioners on new technologies or unknown conditions in patients for whom they care • Communication networks for practitioners to share information, best practices and advice.

Conclusion All nurses must have the competence to obtain and identify data, collect and record such data, and then analyse and interpret information which they obtain from and about the patient to ensure that the patient receives optimal treatment and care. Good information management is an essential tool in the delivery of quality health and nursing care.

Suggested activities for students Activity 4.1 Find out what the system for recording patient information is in the unit where you work: • Discuss with your group the benefits, disadvantages and potential problems you may experience with this system. • Prepare and demonstrate the capturing of the patient’s information on admission. • Prepare and demonstrate how the patient’s information is retrieved if notes were to be required on the patient’s progress. • How effective is this system for access of records?

Activity 4.2 Search for information on the effect of cellphones on electronic equipment. Report to the class what the evidence says about this topic.

Activity 4.3 Create a checklist with the criteria for good record keeping from the information in this chapter. Use it to evaluate the patient records in the unit where you are currently placed for clinical learning. Discuss the results in the classroom.

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chapter

5

Introducing the concept of biopsychosocial needs

Learning objectives On completion of this chapter, the student should be able to do the following: • Assess and plan for the identified needs of the patient satisfactorily and within the professional, ethical and legal framework of nursing and healthcare. • Apply the relevant nursing theories in meeting the needs of patients. • Provide, competent and effective care to patients with bio-psychosocial needs. • Demonstrate tolerance and a positive attitude for diverse customs regarding diet, illness, death and dying, rituals etc, for all patients.

Key concepts and terminology Bio-psychosocial needs: The totality of factors required for physical survival and optimum physical function, as well as factors necessary for social function, psychological wellbeing and spiritual meaning. Needs: Requirements that must be met in order to ensure the successful achievement of a desired goal. Physical needs: The factors which are necessary for the optimum and psychological functioning of the body. Psychosocial needs: A variety of cognitive, emotional and interpersonal factors which enable individuals to adapt to the environment, form relationships with others and function successfully within a community. Religion: An experience of spiritual belief through a framework of rituals, codes and practices, the sense of otherness or a power of being a deity or Supreme Being. Spiritual needs: Those factors that will enable the individual to find meaning in life and a relationship with a higher power such as God, or alternatively with the Universe or forces of nature.

Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy and physiology of the human being 

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• The fundamentals of psychology and sociology • Basic human nutrition.

Medico-legal considerations The needs of patients are diverse and closely related to the disease or condition that has afflicted them. Meeting the bio-psychosocial needs of patients is within the framework of the scope of practice of the nurse, so failure to do so might constitute professional misconduct and negligence as well as adverse legal repercussions for the attending nurse. For example, the use of restraints on a restless patient without a doctor’s prescription could lead to charges of unlawful imprisonment against the nurse by the affected patient.

Key ethical considerations Breach of confidentiality of a patient’s information may constitute an ethical problem in relation to the patient’s need for security, nutrition, oxygenation or any other biopsychosocial need.

Introduction Meeting the health needs of patients is at the centre of nursing as a discipline. Using the nursing process, the nurse determines a deficit in one or more health needs of the patient. Based on the identified deficit, an individual care plan is designed to meet these needs. The nature of the need could be multifaceted and may include biological, psychological or social dimensions, hence the bio-psychosocial needs

Bio-psychosocial theories Humans are conscious beings whose existence comprises physical or biological, social, psychological as well as spiritual dimensions. Nursing is concerned with caring and showing compassion for others, stemming from the belief that life has an intrinsic value and that human worth is paramount when helping those in need of care. Caring, compassion and the recognition of the importance of life are foundational values of nursing, and as such are expressed through the nursing actions aimed at restoring or maintaining an optimum state of physical, mental and social wellbeing. Basic human needs are the same for every individual and although each one of us may have additional special needs, our fundamental needs remain the same as they constitute our requirements for daily living. The literature provides some theories which further explain the place of biopsychosocial theories as fundamental in explaining the phenomenon of patient needs as well as the role of nurses in meeting them. Nursing theorists agree that every individual is a unique being with biological, social, psychological and spiritual dimensions. The role of the nurse includes meeting the needs of patients in order to assist and support them in their recovery from illness. 100

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Nancy Roper This nurse theorist identified specific activities that are necessary in order to maintain life. Her perspective is similar to that of Virginia Henderson, who also described the 14 components of daily living, which are as follows: • Maintaining a safe environment • Breathing • Eating and drinking • Eliminating • Personal cleaning and dressing • Controlling body temperature • Mobilising • Working and playing • Expressing sexuality • Sleeping • Dying • Avoid dangers in the environment • Worship according to one’s faith • Learn, discover or satisfy curiosity that leads to normal development (Younas & Sommer 2015: 445). Hildegard Peplau This theorist reinforced the concept of nursing as assistance and facilitation in the process of attaining and maintaining optimum health. She views nursing as a science and as an interpersonal process between nurse and patient, and from this the concept of the therapeutic relationship is derived, as well as the therapeutic use of the self. Peplau’s approach is particularly valuable in relation to communication and the understanding of the relationship between the patient and caregiver. Abraham Maslow The psychologist Abraham Maslow developed a theory of needs which places human needs on a hierarchy based on their relative importance for physical survival. The needs are arranged in descending order from superior to basic, but are discussed here in an ascending order where the basic needs must first be met before attending to those higher up in the hierarchy. According to Maslow’s theory, basic physiologic needs such as air, food and water, safety and shelter determine survival, and must be satisfied first before the next level of needs can enjoy attention. Individuals using healthcare facilities usually have one or more unmet basic needs, which the nurse must identify and meet, or help the patient to meet. Although people generally have all of the needs as set out by Maslow, the factors impacting on them vary among individuals. All patients must therefore be individually assessed and the nature of their needs and the reasons they are unmet must be determined. Maslow’s hierarchy of needs has been superseded by other theories in the field of social sciences, but the theory nevertheless remains useful for nurses as it facilitates an understanding of the relative importance of the various human needs, and it enables nurses to assign appropriate priority to the needs of patients.

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Self-actualisation

Love and affiliation needs

Esteem needs Safety and security needs

Physiological needs

Figure 5.1  Maslow’s hierarchy of needs

Physical needs Physical needs are described as being the factors required for the optimum physical and physiological functioning of the body. Physical needs include physiological processes, as well as physical activities and adaptation processes, all of which enable an individual to function with optimum efficiency and respond appropriately to the environment.

Need for oxygen The need for oxygen is the most fundamental physiological need. All tissues of the body require oxygen for survival, as oxygen is essential for the final extraction of energy from foodstuffs. Oxygenation includes the uptake and utilisation of oxygen by the tissues and the concurrent elimination of carbon dioxide from the tissues. The process of oxygenation includes the following: • Breathing • The exchange of gases in the lungs • The transport of oxygen to the tissues in the blood through circulation • The uptake and utilisation of oxygen by the cells • The transport of carbon dioxide in the blood • The elimination of carbon dioxide from the body via the lungs • An unmet oxygen need may be due to any factor that interferes with these processes, such as lack of oxygen, inadequate pulmonary ventilation and gas exchange, inadequate circulation, or poor tissue uptake and utilisation. Need for circulation Circulation refers to the movement of blood and plasma through the blood vessels, propelled by the pumping action of the heart. Circulation is the means by which the tissues of the body are supplied with oxygen and nutrients. Adequate circulation is necessary for the proper physiological function of the body. Any factor that interferes with the pumping action of the heart, the volume of blood in the blood vessels or the patency of the blood vessels will impede circulation.

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Need for fluids and electrolytes The body maintains a balance in respect of its uptake and utilisation of water and salts. The correct amounts of fluid and dissolved salts or electrolytes are essential for a variety of chemical and metabolic processes in the body. Maintenance of fluid and electrolyte balance includes the following: • The intake of fluid and dietary salts • The formation of urine and the elimination of excess fluid and salts • The maintenance of a constant pH in the body fluids. Need for nutrition Nutrients are the raw materials that the body uses for energy, to build and repair tissue, and to synthesise enzymes, hormones and other molecules required by the body. Nutrition refers to the taking in, utilisation and storage of foodstuffs. Human nutrition includes the processes of feeding, as well as those of digestion, absorption and the metabolism of foodstuffs in the body. Socio-economic circumstances, as well as the cultural background of a patient, may influence nutrition needs. The culture as well as the preferences and income of the patient must be considered when meeting this need. Need for elimination of waste products Elimination refers to the expulsion of bodily wastes. The body constantly produces waste products, such as urea and carbon dioxide, during the processes of metabolism. These waste products are toxic to the body and must therefore be eliminated. Some elimination takes place via the skin (small amounts of urea), and the lungs are responsible for the elimination of carbon dioxide. The principal routes of elimination are, however, via the kidneys and the gastro-intestinal tract. The processes of elimination include the following: • Defecation • Formation of urine by the kidneys • Micturition. Need for temperature regulation Humans are mammals, which means that their body temperature is maintained within a narrow range irrespective of the temperature of the environment. The physiological functions of the body take place within a narrow temperature range of 36.2–37.2°C. When the body temperature leaves this normal range, the results are altered metabolic processes, injury to cells and tissues, and ultimately death. Exposure to heat and cold, as well as pyrexial conditions, affects the body’s ability to keep the temperature within the normal range. Need for mobility and exercise Every individual executes a variety of bodily movements in the course of his or her normal daily activities. In addition, many individuals engage in some form of exercise or sport. The need for purposeful movement and exercise includes not only the capacity for normal bodily movement but also the capacity for exertion and strenuous physical exercise. The ability to meet this need depends on a variety of factors: physical fitness and strength, neuromuscular function, and musculo-skeletal agility. 103

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Need for hygiene The word ‘hygiene’ refers to the science of health and its preservation; in particular, the word refers to cleanliness, both of the individual and the environment. Individual hygiene needs relate to the maintenance of personal cleanliness and grooming. Hygiene needs include personal habits and practices regarding personal care and the grooming of the body; practices that are frequently influenced by culture. Environmental hygiene also influences health, and many diseases, such as asthma and other upper-respiratory problems, can be directly related to pollution and less than ideal environmental conditions. The need to maintain optimum environmental hygiene can also be considered to be a human need. Need for comfort and rest The word ‘comfort’ refers to a sense of ease and wellbeing. Physical comfort means not only the absence of pain but also includes the following: • The position of the body • The temperature of the environment • The absence of hunger or thirst • The absence of annoying distractions and stressful happenings. Rest is closely allied to comfort, and refers to a state of physical inactivity, repose and relaxation. Sleeping and waking, as well as factors that might induce restlessness, must be taken into account. Physical and emotional stress may interfere with an individual’s ability to rest. Rest and sleep are essential for normal physical and psychological function in order to replenish energy and repair tissues.

Need for safety In the physical sense, the need for safety means the avoidance of physical injury and damage to the body. The individual’s level of consciousness and awareness, as well as the individual’s level of physical fitness and agility are relevant to this need. The need for safety also includes psychological safety, or the feeling of being secure and of knowing what to expect from the people around one, as well as being able to cope with events. Psychological safety means that individuals understand what is happening and trust that their best interests will be safeguarded. Need for security Security is based on physical safety, which means adequate food and shelter, as well as freedom from physical harm. Security is all-encompassing and it is a broader concept than physical safety. It relates to the following: • A state of comfort within one’s environment, meaning that individuals are assured of the means with which to support themselves in society. This implies that they are comfortable with their role and satisfied with their position in society. • Protection under the law from the violation of fundamental rights. This includes the right to privacy and confidentiality, as well as a sense that the individual knows where he or she stands in relation to a rational and basically good society through being able to find respect and support within that society. • Free access to institutions and facilities is also necessary for security. 104

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Need for sexuality In the physical context, sexual or reproductive needs refer to those actions or processes that are necessary for the reproduction of the species. These include copulation, conception, gestation and parturition. Sex needs are influenced by a variety of factors, such as age, sociocultural background, ethics, self-concept and physical fitness. Sexuality is more than a physical need because of the psychological and cultural dimensions, and these aspects must be taken into account when dealing with patients. The physical ability to engage in sexual activity may be affected by illness, disability, drugs and stress, and nurses must be aware of the importance of sexuality and of the ways in which it may be affected by medical treatment and nursing care. Nurses must also be aware of patients’ need for information about sexual activity and ways in which sexual activity is altered according to the health status of the patient. Comprehensive history taking on the first visit to a health facility should include the following: • History of any sexually transmitted diseases (STDs) • Sexual activity or practice • Sexual orientation • Sexual dysfunction.

Psychosocial needs Psychosocial needs refer to a variety of cognitive, emotional and interpersonal factors that enable individuals to adapt to the environment, form relationships with others and function successfully within a community.

Need for cognition The word ‘cognition’ comes from the Latin cognoscere, meaning ‘to know’. In order for an individual to function adequately in relation to the environment, to other individuals and to the community, effective thought processes must be developed. Effective thought processes include orientation to the environment and the people in it, as well as problem-solving skills and the ability to form concepts and organise thoughts in a logical manner. Memory and the ability to understand and learn are also necessary for adequate cognition. Need for adaptation In order to be able to deal with stress and life events effectively, individuals must develop a variety of conscious coping skills. Coping behaviours involve the use of problemsolving techniques and relaxation, as well as the avoidance of stressful situations. Healthy coping implies adaptability and the capacity to deal with change rationally and appropriately. Less-healthy coping mechanisms include aggression, withdrawal and substance abuse. Unconscious coping behaviours include defence mechanisms such as denial, projection, repression and regression. Coping skills are more difficult to assess in children, but it is true to say that children who are able to make their needs known and who are confident of having them met are coping effectively. Severe stress in a child may bring out primitive defence mechanisms such as temper tantrums, withdrawal and regression.

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Need for self-esteem and self-concept • Self-esteem implies that one regards oneself in a positive way. Self-confidence and self-esteem are the basis of sound interpersonal relationships and mental health. A healthy self-concept requires acceptance of one’s personality traits, as well as a realistic perception and acknowledgement of one’s faults. Adequate selfesteem requires acceptance of the self and feeling good about the self. This includes acceptance of bodily appearance and characteristics. Good bonding in an infant is a prerequisite for the development of self-esteem. A child with good self-esteem will show confidence and be outgoing. Adequate role performance is related to selfesteem needs, as every individual has a need to fulfil his or her various life roles effectively. • Self-concept relates to how one feels or thinks about oneself. The components of self-concept include identification, body image, role performance and self-esteem. A healthy self-concept requires acceptance of one’s personality traits, as well as a realistic perception and acknowledgement of one’s faults. • Self-confidence is based on a healthy self-concept and self-esteem, which are the basis of sound interpersonal relationships and mental health. Need for autonomy Autonomy implies independence, control and the competent management of the cognitive, perceptual and behavioural processes of an individual within the societal definitions of ‘normality’ or ‘mental health’, and conforming to accepted social norms. Autonomy also includes the facility of choice, or the ability to make an informed decision between several alternatives, based on personal beliefs and preferences. The ability to exercise choice also implies the right to have those choices respected. Need for relatedness Humans are social beings and need the esteem and co-operation of their fellow human beings. Human beings also have a need to form close associations with others, as the fullest expression of the personality is attained within reciprocal human relationships. Different types of relationship are characterised by different degrees of self-disclosure. Close intimate relationships demonstrate mutual trust and support, as well as mutual esteem building. The nurse–patient relationship is a special type of relationship in that it is intimate and caring without being too close – the nurse knows and cares for his or her patients but does not become emotionally involved with them. Several relationships are identified: • Nurse–patient relationships are also characterised by empathy and a disinterested concern for the patient’s best interests. During their lifespan, individuals will form many relationships with others. Most of them will be superficial as in casual friendships, and a few will be close, as in marital relationships. Individuals need to learn to adapt their behaviour according to the degree of closeness of the relationship. • Family relationships are influenced by the indivual’s role in the family, for example as father, mother, daughter, son, etc. • Significant-other relationships are characterised by emotional ties with one another or other factors. 106

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Need for stimulation Curiosity is one of the most striking features of human nature. People have an innate need to explore, to develop their potential, to respond to challenges and to achieve. Stimulation is essential for the development of human potential. The environment, education and interaction with other people are all crucial for development. Stimulation also includes the need for leisure-time activities, during which individuals express themselves in an informal and pleasurable way. Meaningful work, on the other hand, is an important source of stimulation as it enhances self-esteem. Need for communication Communication with others is a natural human activity that is essential for survival and for the formation of meaningful relationships with others. Communication is the process of giving and receiving information, and of attaching meaning to information and making use of that meaning. Communication is a major factor in determining the relationships that people have with others and what happens to them in the world. Table 5.1  Summary of bio-psychosocial needs Physical needs

Psychosocial needs

Spiritual needs

Oxygen

Cognition

Meaningfulness

Circulation

Adaptation

Religious expression

Fluids and electrolytes

Self-esteem and self-concept

Nutrition

Autonomy

Elimination

Relatedness

Temperature regulation

Stimulation

Skin integrity

Communication

Mobility and exercise Hygiene Comfort and rest Safety Security Sexuality

Spiritual needs Need for meaningfulness Meaningfulness implies the need for meaning and purpose in an individual’s life. Finding meaning in life requires the development of a personal philosophy and ideology, and the ability to explain life events in the light of this. Individuals also have a need to find meaning in pain, suffering and death. The meaning attributed by patients and their 107

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families to pain, suffering and death, for instance, will impact heavily on the demands made on healthcare services and on healthcare workers. Grieving is an essential part of finding meaning in pain, suffering and death. Both patient and family may need to grieve in order to accept and work through the illness or death of a loved one. Nurses must be aware of these needs, and facilitate the process through good nurse–patient– family relationships. Participation in a system of spiritual belief, whether formal or informal, helps to give meaning to life, as does achievement and the knowledge that one has led a full life with few regrets. Meaning in life is frequently connected to self-esteem and relatedness, as many people find meaning and self-expression in their relationships with others and with a Supreme Being.

Need for religious expression For most human beings, spiritual needs are fulfilled within an organised system of belief and worship, whether formal or informal. The religious beliefs and practices of an individual form an important part of that individual’s life, particularly in relation to beliefs and practices about birth, death, health and illness. Religious practices and rituals play an important part in enabling individuals to weather life’s crises.

Conclusion Bio-psychosocial needs are all-encompassing, starting from the most basic of needs – those for survival – to the highest of needs such as social self-esteem, social recognition and self-actualisation. These needs are fundamental to nursing care as nursing is built on meeting patients’ needs. Care plans are drawn to meet individual needs, so it is imperative for student nurses to learn about needs and how to reconstruct them into nursing diagnoses. For example, a patient who has no appetite has an altered nutrition need, and the nursing diagnosis will be altered nutrition due to the disease process. In such a case, a care plan will be drawn up to ensure that the patient’s appetite is restored.

Suggested activities for students Activity 5.1 Select the most appropriate answer from the given choices in the following multiplechoice questions: 1. In meeting the nutritional needs of a dependent patient, when the food you want to serve the patient is too hot, you should: a. return the food to the trolley uneaten b. blow on the food to cool it c. leave the food until it cools d. put the food in the refrigerator. 2. When feeding a patient who is paralysed on one side of the body, direct the food to: a. the unaffected side of the mouth b. the affected side of the mouth c. the centre of the mouth d. the back of the throat. ➙

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3.

Empathy means: a. understanding how the patient feels b. feeling sorry for the patient c. understanding emotional needs d. solving problems for the patient.

4.

Needs on the lowest level of Maslow’s hierarchy include: a. love b. safety c. food d. self-esteem.

5. In order to effectively meet the elimination needs of a patient, the nurse should understand that the most serious form of constipation is: a. flatulence b. distension c. impaction d. obstruction.

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Recognising spiritual needs

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate an understanding of patients’ beliefs and customs by the manner in which he or she relates to patients and their families. • Recognise and respect patients’ constitutional rights to religion and culture. • Provide an appropriate environment for carrying out religious sacraments and rituals. • Carry out a comprehensive assessment on admission of every patient in order to identify customs, including dietary customs that should be taken into account in planning the subsequent care. This history will indicate whether the patient would require a visit by a minister of religion or spiritual guide. • Pay special attention to patients’ religious customs that may impact on treatment. • Provide special diets in accordance with religious custom, while taking any relevant treatment aspects into consideration.

Key concepts and terminology Culture: A way of living, thinking and behaving usually inculcated during socialisation. Custom: Usual or established way of behaving. Euthanasia: A procedure which brings about easy and peaceful death of another (also called mercy killing). Intuition: A feeling or insight about something. Meditate: To think, contemplate and exercise the mind. Myriad: Many or great numbers. Ontology: A philosophical system of understanding existence. Spiritual needs: Needs that the individual seeks to satisfy in order to find meaning in life and a relationship with a higher power such as God, or alternatively with the Universe or forces of nature. Suicide: The intentional killing of the self. Unction: A religious rite of anointing someone with oil.

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Medico-legal considerations • In cases where beliefs and customs specifically forbid certain forms of medical treatment, for example the giving of blood in the case of Jehovah’s Witnesses, the deliberate disregard of such prohibitions may involve both the nurse and the institution in legal action. Where the patient is mentally capable, refusal of treatment must be respected. If the patient is incapable – that is, unconscious or confused – and in the absence of the family, the medical practitioner concerned is obliged to act in a manner that he or she considers to be in the best interests of the patient. This could unwittingly involve some disregard of religious beliefs and customs, but the practitioner would not be held liable in such circumstances, provided that action was taken in good faith. • In the case of children whose parents’ religion prohibits certain forms of treatment, the courts may overrule the parents if the treatment is in the best interests of the child. In practice, this course of action is seldom advisable, as it can lead to severe family conflict, sometimes resulting in the rejection and/or abandonment of the child. A patient may only refuse treatment on religious grounds for him- or herself, and not for others. • Where limbs or organs are to be surgically removed, the patient and family may ask to be given the removed part for burial. The manner in which this request is dealt with will depend on the institution and the medical practitioner concerned. Where possible, this should be respected and accommodated. In circumstances where it is not possible to let the family take the amputated part for burial (eg if the part is needed for laboratory analysis and testing), the situation should be tactfully and sympathetically explained to the family. It is usually helpful to involve a minister of religion in discussions with the family. • Refusal of consent for post-mortem examination should be respected, except in cases where the examination is required on medico-legal grounds.

Ethical-legal framework The right to one’s religion and culture is enshrined in the Bill of Rights in the Constitution of the Republic of South Africa, therefore every patient visiting a health facility or being admitted to hospital would expect his or her rights to be respected and not violated. Deliberate disregard of important beliefs and customs is a denial of the rights of the patient. For example, in cases where beliefs and customs specifically forbid certain forms of medical treatment, for example the giving of blood and blood products in the case of Jehovah’s Witnesses, the deliberate disregard of such prohibitions may involve both the nurse and the institution in legal action.

Introduction In a multicultural society, the nurse will encounter a wide spectrum of religious beliefs and customs. The nurse must therefore be aware of the different religious and spiritual belief systems and the importance of these, and must be capable of accommodating

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this aspect in nursing care. The nurse will be expected to deal with these beliefs and customs with respect, no matter what his or her own religious beliefs may be. The information that follows is intended to provide a brief overview of the major faiths and belief systems that the nurse is likely to encounter. The chapter also introduces some significant customs that may need to be accommodated in nursing care. From a patient’s perspective, the holistic care that is expected includes the freedom to seek or expect emotional and informational support from the nurse. Good communication skills, both verbal and non-verbal, are vital in this regard. Although this is an introduction to the topic of spirituality and is by no means exhaustive, it is hoped that the nurse will be able to build up a core of knowledge. Nurses are encouraged to develop an openness and keenness to learn more about their patients’ beliefs and customs, which will enable them to offer holistic and culturally congruent care. By developing this knowledge, they will be in a position to offer more effective and empathic support. Some nursing competencies for spiritual care will be highlighted in this chapter.

Spirituality and religion The importance of providing spiritual care to patients is well documented in nursing literature. However, until recently there has never been a clear explanation of what spiritual care entails, including the specific competencies required by the nurse in order to provide this type of care. The concepts of religion and spiritual care are often used interchangeably. However, Monareng (2012) defines spiritual nursing care as a process that begins from a perspective of being in a dialogue with the patient about his or her therapeutically oriented religious or spiritual beliefs. According to Sawatzky and Pesut (2005), spiritual nursing care is care that is embodied in the nurse’s respect for the patients’ dignity, unconditional acceptance, love, honesty and the fostering of hope and peace. Spirituality is therefore a broader term than religion. Religion, on the other hand, encompasses a belief system where spirituality is expressed through a system of values, rituals and other practices.

Meeting the spiritual needs of patients Assessment of patients on admission should include a comprehensive history taking regarding the patient’s religious beliefs with regard to health and illness. This is to ensure that these beliefs and practices are taken into consideration when planning nursing care, as well as their impact on medical treatment and procedures. Very often, nurses will ask only about the patient’s religious affiliation and not delve into the specific health beliefs or practices that may impact on healthcare. Given the knowledge that spiritual needs are legitimate and proven, and that meeting these needs will benefit the health of a patient, the nurse should develop the intuition and expertise to be able to assess these needs. Prior to this, however, nurses should assess themselves. They should know their own professional identity – who they are and what their purpose is. Each nurse should have a personal philosophy of nursing as a guide. It is important to realise that each patient has a culture and a belief system associated with that culture, and that good nursing care includes understanding that belief system.

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• Listening: The first thing that people in the caring professions should learn to do is to listen. We listen not only with our ears but also with our eyes, with which we read the patient’s body language. Indeed, body language will often tell us far more about the patient’s state of mind than what he or she is saying. • Sympathy: Patients will never expose their innermost secrets and fears if they do not feel safe, and this safety can be achieved only through a caring and sympathetic attitude from health professionals. This means that the patient needs to be assured that the nurse is genuinely interested in his or her thoughts, feelings and experiences. Because of the nurse’s sympathetic attitude, the patient can speak freely and honestly, and the nurse can evaluate and diagnose the patient’s need. What the patient reveals will consist of content or the factual details of thoughts, emotions or feelings about that content, and implications or tentative decisions based on content and emotion. Valuation and diagnosis reveal the needs of patients. These needs can then be met by speaking to the patient (conveying verbal consolation, information and therapy) and accompanying the patient (supporting the patient and doing something practical to help). Negative mood conditions, including spiritual distress, are created by what are known as cognitive distortions. Some examples of cognitive distortions related to health are given below: • All-or-nothing thinking: The patient sees things as totally good or totally bad. For example even if the patient’s health is only minimally affected, the patient thinks that he or she is going to die. • Blanket generalisations: A single health problem or setback is viewed as a neverending pattern of defeat and ill health. • Mental filtering: The patient picks out the negative aspects of his or her condition and dwells on them to the exclusion of the positive. Eventually the patient’s whole perception of reality becomes darkened, and he or she may become clinically depressed. • Disqualifying the positive: The patient rejects positive events and maintains negative beliefs. For example, successful medical treatment is viewed with scepticism, and the patient feels that the effect will not be permanent. • Jumping to conclusions: The patient arbitrarily reaches negative conclusions about his or her treatment or condition, for example thinking that the doctors and nurses do not really care, or concluding that he or she is going to die. • Magnification and/or minimisation: The negative is magnified out of all proportion while the positive is minimised or dismissed as being unimportant. • Labelling and mislabelling: The patient attaches a negative label to him- or herself, instead of describing the situation or problem, for example ‘I am a loser’; ‘I am a sinner, and this is why I am sick’; or ‘I am bewitched’. • Personalisation: The patient sees him- or herself as the cause of the illness, but this is in fact not true. Cognitive distortions like these can play havoc with a patient’s state of mind during illness. Illness and pain stir up many cognitive distortions and biases. When we consider

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the experiences of ill patients, it becomes understandable that their thinking can go awry and become distorted. The emotional responses of patients include psychotic, neurotic and behavioural reactions to the real or fantasised threats posed by their illness or injuries. Their experience is mainly one of stress. Any threat (eg illness, surgery or anaesthesia) marshals coping mechanisms. The specific problems threatening the traumatised and stressed patient include the following: • Helplessness: In any illness, people become dependent on someone else for healing and comfort. The defence of regression follows dependence. Caregivers are viewed as protecting or parental beings. The more severe the physical injury, the more intense the patient feels the abandonment and separation from family. The degree of regression is proportionate to the severity of the injury and intensifies patients’ magical expectations of their helpers and also of God. • Humiliation: Injury and hospitalisation also engender desperate feelings of indignity in reaction to hospital procedures, for example the bedpan, catheters and the taking of blood samples. Exposure of the body adds to the sense of humiliation experienced by a patient. • Body image: Body image is the conscious and unconscious concept of the physical appearance that patients have of their bodies. Body image can also include the car and clothing or the perception of the environment, all of which contribute to a sense of identity. In severely traumatised patients, the threat of mutilation of the body is often an overwhelming burden. • Mental symptoms: Patients may experience an altered mental state or an altered state of consciousness due either to physical or emotional causes. Further examples of the spiritual distress of patients include the following: • Expressing concern with the meaning of life, death or a particular belief system • Anger towards God, the forefathers or significant others • Questions about the meaning of suffering • Seeking spiritual assistance • A sense of having failed God, or a sense of sinfulness • Lack of reconciliation with God and ignorance about the grace and forgiveness of God • A sense of powerlessness and loneliness related to separation from religious ties • Ignorance about the power of prayer. In order to help their patients, it is of paramount importance for nurses to understand their perspective – that is, where they are coming from. To do this, nurses must not only possess a basic fund of knowledge relating to cultural and religious beliefs, but must also establish a relationship of trust with their patients. In nursing terms, this involves the following: • First verify the patient’s perceptions and cognitive distortions with the patient himor herself or with the family. • Each identified misconception should be carefully dealt with and corrected. This could involve explaining the patient’s condition and treatment to him or her, and ensuring that he or she has a clear understanding. A talk with the doctor concerned 114

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could be arranged. Nurses should be constantly attentive to their patients to allow them every opportunity to ask questions and clarify matters. Nurses should always explain everything that is done to the patient in order to maintain the patient’s participation and co-operation, and allow further opportunities for questions to be asked.

Principles of spiritual care The principles of spiritual care include the following: • Recognition and acceptance of the spiritual dimension of human beings • Comprehensive assessment to determine the patient’s spiritual and religious needs • Good communication, and a need to listen in an authentic manner to enhance a trusting relationship • Empathy and the ability to accept what the patient says • Use of judicious self-disclosure • Referral to professionals more qualified in spiritual care, for example the hospital chaplain or the religious leader of the patient • Genuine concern for the patient’s welfare, including answering questions with honesty and respect • Displaying a positive attitude all the time. Some examples of screening questions to ask in eliciting spiritual needs Questions • What can I do to support your faith or religious commitment? • Are there aspects of your religion or spirituality that you would like to discuss? • Would you like to discuss the spiritual or religious implications of your health?

Clinical alert! It may be necessary for the nurse to determine the specific concepts of spirituality and religion in the patients’ language in order for the responses to the questions to be meaningful.

Nursing competencies for spiritual care Nursing alert! Nurses should refrain from imposing their own belief system on the patient, as this might cause distress to the patient.

Baldacchino (2006) identified four main competencies that are intertwined with the role of the nurse as a professional practitioner as well as an individual human being. They include the following: 115

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• • • •

Using the nursing process to deliver spiritual care Communication with patients Interdisciplinary team and clinical/educational organisation Safeguarding ethical issues in care.

Need for religious expression For most human beings, spiritual needs are fulfilled within an organised system of belief and worship, whether formal or informal. The religious beliefs and practices of an individual form an important part of that individual’s life, particularly in relation to birth, death, health and illness. Religious practices and rituals play an important part in enabling individuals to cope with life’s crises, including ill health. In a multicultural society such as South Africa, nurses need to be familiar with the major religious practices in the country. All cultural and religious affiliations are recognised in the Constitution.

Belief systems of the major religions Christianity Christians find guidelines for living in the following sources: • The life and teachings of Jesus Christ, as expressed in the gospels • The teachings of the Church • Their own individual consciences, taking into account that conscience has been developed in the light of the teachings of Jesus and of the Church. These sources give rise to Christian beliefs about humankind, the world and the universe. To Christians, life is not meaningless. God has created life in all its aspects. Although life can be very painful, and suffering can be immense, human beings are made in the image of God and can find redemption and a personal relationship with God through belief in Jesus Christ. In the gospels, Jesus teaches that people need to be changed from within, and this idea is often referred to as being ‘reborn’. Gospel teachings are about human beings rising above the violence, hedonism and materialism of their present experience, and developing and evolving as spiritual beings through salvation that comes through Jesus Christ. The gospels further teach us that people are capable of a relationship with God through Jesus Christ, and of undergoing a definite inner development and change, making them more Christ-like and compassionate towards their fellow human beings. Christians believe that, because humans are spiritual beings, the small voice of conscience comes from God. Christians also believe that because human beings are far from perfect, they cannot do right without God’s help, and this help is called grace. Christians believe that prayer is an important way of becoming tranquil inside so that God can be heard and communicated with. For Christians, human relationships are very important, and Christian teaching in this regard can be summed up in the quotation from Matthew’s gospel: ‘Treat others as you would like them to treat you’ (Matthew 7:12). Christian teachings regarding people and relationships teach the virtues of respect, concern, empathy, compassion, love, tolerance, honesty and selflessness. 116

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Christianity and body matters

Christians believe that the human mind and body are a temple of God, because God’s Holy Spirit dwells within the mind and spirit of believers. Most Christian denominations therefore believe that abuse of the body and/or the mind is destructive and goes against God’s purpose for humankind. • Christian teachings always encourage moderation, the avoidance of extremes, and the cultivation of a balanced lifestyle. • Alcohol, if abused, is extremely dangerous for individuals and for society. Some Christian denominations, such as members of the Salvation Army, never drink alcohol, while others believe that alcohol can be one of the pleasures of life if used wisely and taken in moderation. Certainly, in the New Testament, Jesus himself is sometimes pictured drinking wine and even turned water into wine at Cana. • Generally, smoking is discouraged because it renders an individual prone to illness and premature death. Smoking also pollutes the body, which is God’s creation. The extent to which the various denominations apply this general view varies. • Most Christian churches believe that to abuse the body and the mind with drugs is wrong. • Euthanasia and suicide are condemned by most Christian denominations, as the ending of one’s life by choice, whether by one’s own hand or that of another, is seen as a rejection of God’s gift of life. Christians believe that meaning may be found even in the midst of profound suffering if the mind is focused on God. This belief underlines the importance of spiritual care as part of nursing care. • Some Christian groups reject certain forms of medical treatment, such as blood transfusion. • The Church believes that sexual acts should take place only within the framework of marriage, and Catholics believe that artificial forms of contraception, as opposed to ‘natural’ methods, are contrary to the purpose of marriage. The Church generally condemns abortion. The manipulation, freezing or leaving to die of test-tube embryos is also condemned as the Church holds that each embryo, however conceived, is a potential human being and has a right to life. • Homosexuality is generally condemned as being abnormal, but some denominations will give qualified acceptance to relationships that are permanent, committed and characterised by love. • Most of the Protestant denominations hold that couples may practise forms of contraception that are acceptable to both partners. Abortion on demand is usually condemned as a form of birth control, although termination of pregnancy may be permitted if the life of the mother is in danger.

Specific nursing implications • Most patients, if they are practising Christians, will appreciate a visit from their pastor, or possibly a prayer group from their church. Nurses should facilitate this if requested. ➙

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• For Roman Catholic patients, it is important to approach death in a state of grace, the individual having confessed his or her sins and reconciled him- or herself to God. Seriously ill Roman Catholics will therefore often request that a priest be called in order to hear their confession and to administer communion. The priest gives extreme unction to patients who are close to death. This rite is comforting and reassuring to both patient and family. • For patients who are Anglicans, receiving Holy Communion while sick in hospital is important, and most Anglican hospital chaplains are keen to know about Anglican patients so that Holy Communion can be offered. If a patient is to receive Holy Communion, the nurse will usually be asked to screen off the patient’s bed in order to provide privacy. The placing of a white cloth on the locker or a flower, if available, adds a nice touch. • Jehovah’s Witnesses will refuse blood transfusions, as they believe that this will prevent them from going to heaven. • Some denominations may refuse permission for post-mortem examination, and this should be respected unless the post-mortem is for medico-legal reasons, in which case the law overrides the objections of the family. It is. However. always desirable that the family’s wishes be accommodated as far as possible rather than to have the courts settle such matters. Should this be the case, the nurse should see to it that the family is given appropriate explanation and support. • Some denominations insist on burial and will not consent to cremation. The rationale for this lies in the belief that a person cannot be resurrected at the Second Coming of Christ if the body has been cremated. • In all cases of seriously ill or dying patients, the family should be allowed to remain with the patient in order to give spiritual and psychological support. Supporting and reassuring family members who are sitting with a dying patient is an important facet of nursing care.

Judaism Judaism teaches that, without God, human beings are unable to create their own morality. People can apply moral guidelines, but God must first give those guidelines to them. For Jews, these guidelines are set down in their holy book, the Torah. The guidelines are expressed in the form of mitzvoth: commandments that Jews are expected to live by. These commandments are summed up in the Ten Commandments, given to Moses by God on Mount Sinai. The Torah tells of many other commandments that God told Moses to teach the people. There are 613 altogether, embracing every area of life. The application of these laws is considerably expanded upon in the Talmud, which is a collection of the teachings of the Jewish spiritual leaders, or rabbis. The principles of Jewish morality can be summed up in five points: • God created people to serve Him. • Moral behaviour is an essential aspect of serving God. • By serving God, people refine themselves and bring holiness into the world. • People could not have known how to do this, so God gave them commandments. • Keeping the mitzvoth, and making them one’s normal standard of behaviour, allows people to develop as human beings.

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Judaism and body matters

• In the Jewish teaching, keeping the body clean and healthy is a religious duty. This does not mean that Jews are encouraged to go to extremes, but it does mean that a Jew is expected to treat the body sensibly, to keep it clean, and to avoid anything that might harm it. • Devout or orthodox Jews follow a system of dietary laws known as kashrut. According to this system, alluded to in the Torah and considerably expanded in the Talmud, certain foods are forbidden, milk and meat must be separated, and animals for meat must be slaughtered in a certain way. Originally designed to ensure that the Hebrews remained healthy and avoided potential health hazards in food, the kosher way of eating has become part of the manner in which devout Jews express their faith. • Jews are not forbidden to use alcohol. Indeed, they use wine in various religious ceremonies. However, Judaism strongly disapproves of consuming alcohol in large quantities. • Many Jews regard smoking as being inconsistent with their religious teaching, as it is known that smoking is detrimental to health. Some rabbis believe that there are sufficient grounds to forbid smoking according to the Torah, especially since the connection between passive smoking and ill health has become widely known where smoking may cause harm to someone else, not just the person smoking. • With regard to drugs, devout Jews believe that putting oneself at risk through addiction is tantamount to rejecting the Creator’s will. • Some rabbis have welcomed the advent of genetic engineering, as it is proving useful as a means of eliminating genetic disorders. Most rabbis would like to see safeguards because of the potential for abuse and the inherent ethical dilemmas. • Judaism does not approve of suicide. Jews see God as the giver of life, and He is the only one who has the right to take it away. Jews will not bury a suicide victim alongside other Jews, but in a separate part of the cemetery. • Judaism sees suffering as an integral part of life, and believes that it is one of the ways in which God tests and refines a person. Although Judaism believes that suffering may have a positive side, Jews believe that every effort should be made to relieve suffering. • In Jewish thinking, killing people to put them out of their misery is murder. Euthanasia is thus forbidden even if a person requests it. The rabbis do, however, permit the withholding of treatment from someone who is beyond medical help. • In Jewish thinking, sexual behaviour is only acceptable within marriage. Although sexual intercourse serves to bring children into the world, Judaism recognises that this is not its only purpose. • Sexual intercourse also serves as a means for two people who are committed to sharing their lives to express their love for each other. For this reason, sex is considered natural and purposeful even beyond the age of childbearing. • The Torah strictly forbids adultery and incest. Among the sexual relationships that the Torah expressly forbids is that between one man and another – that is, male homosexuality. (Lesbianism is not mentioned in the Torah, although later Jewish writings – the Talmud – refer to it with disapproval.) • Judaism forbids prostitution. 119

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• Judaism sees contraception as impeding God’s will. On the other hand, Judaism also sees the preserving of life to be of prime importance. Where it might be hazardous for a woman to become pregnant, the rabbis insist that contraceptives be used. Using contraceptives for convenience, however, as, for example, if a couple delays having children until their furniture is paid off, is not approved. Where contraceptives are used, it is usually only the woman who is permitted to use them, as the rabbis feel that intercourse should be as natural as possible. • In Jewish thinking, abortion is more objectionable than contraception. It not only impedes God’s will but also actually destroys potential human life. The destruction of a viable foetus is sometimes regarded as murder, and is forbidden for Jews and non-Jews alike. At the same time, Judaism does not give the foetus, which is only a potential life, the same importance as the mother, who is actually alive. Abortion is therefore acceptable if a pregnancy becomes hazardous for the mother (or might become so), or if she is likely to be severely affected psychologically. Some rabbis permit abortion if the child is likely to be so retarded that it would never function as a human being. • Judaism permits artificial insemination by the husband (not by a donor), because of the great importance attached to the having and raising of children in Judaism. Some rabbis permit in-vitro fertilisation, although none of them agree with surrogate motherhood.

Specific nursing implications • Orthodox Jews follow kashrut and require a kosher diet in hospital. In most large hospitals, this is available and should be offered to patients. Should a kosher kitchen not be available, a vegetarian diet may be acceptable or the nurse can contact the Jewish community organisations, which will probably be able to help. Alternatively, the family could be allowed to bring food in for the patient. • When a Jew is dying, custom dictates that someone sits with the patient to reassure, comfort and pray with him or her. Traditionally this is a member of the immediate family. When no family is available to perform this duty, the local synagogue or Jewish community organisation can be approached to help. Large hospitals often have a Jewish ‘Wagter’ to perform this duty, although in practice this individual often only comes in to prepare the body after the patient has died. • When a Jewish patient dies, the ‘Wagter’, who is designated by the Jewish community organisation or the synagogue, lays out the body, or this may be done by the family. Nurses do not prepare or lay out the body in any way, other than to straighten it or to remove catheters and drips. When the body is taken to the mortuary, it is placed in a special section of the mortuary designated for Jewish bodies. The Jews bury their dead within 24 hours. • Orthodox Jews will not give consent for post-mortem, and, if a post-mortem has to be performed, careful explanations and reassurances should be given to the family. • Orthodox Jews will also not cremate their dead, as they believe that the dead person cannot be resurrected at the coming of the Messiah if the body that he or she once inhabited has been reduced to ashes.

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Islam Islam is the name given to the religion practised by Muslims. It means ‘submission to the will of God’ or Allah. A Muslim is a person who at some point in his or her life has become aware of the reality of the existence of God, and has committed him- or herself to submission to God’s will as expressed in the writings of the Prophet Muhammad (peace be upon him), known as the Quran (or Koran). Muslims prefer to use the name ‘Allah’ in place of ‘God’, as they believe that the word ‘god’ can be made plural or feminine. Once this awareness, known as taqwa, has begun in a person, life can never be the same again. Every aspect of life is a gift that would not have existed if Allah had not willed it so, and every part of it will cease to exist if Allah wills it so. There is no longer any meaning to fear, or ambition, or ownership, or pride. The human role is not to own or to have, but simply to be. There is only one aim or ambition which continues to make sense, and that is to accept or submit to Allah, so Muslims aim to live out the will of Allah as much as it is humanly possible in whatever life circumstances they find themselves. Islam teaches that every human being is a creation of the one God and that all are born equal. Charity is regarded as being a duty for every devout Muslim and is seen as a way of obtaining blessing. Islam and body matters

• Muslims believe that Allah has created every soul. In other words, no person owns his or her own soul, or is allowed to damage or attempt to kill the body in which it lives. For Muslims to kill themselves is just as much against Allah’s laws as is killing other people unlawfully. • Muslims reject the idea of euthanasia, because Allah will know the reason for any suffering. ‘Mercy killing’ does not always give the affected person any choice. • As far as sexuality is concerned, Muslims value fidelity and sexual chastity, although this often seems to be more incumbent upon women than upon men. Adultery and fornication are forbidden, as is homosexuality. At the same time, many of the customs that relate to sexuality that have come to be associated with Islam are not in fact found in the Koran, but spring from the culture of the peoples who have accepted Islam. The Koran does, however, advocate modesty in women. The Koran also contains many precepts that are designed to protect the rights of women and widows. • Muslims believe that conception should be welcomed, and that parents should not seek an abortion. Muslims do not accept the argument that population growth must be controlled to avoid overpopulating the Earth, or because of poverty, as all of these matters are subject to the will of Allah. Islam does permit some forms of birth control, however, provided that special circumstances justify it. A man may not, however, practise birth control without first discussing it with his wife, and vice versa. Some Muslim scholars believe that the breath of life, or spirit, does not enter the body until the end of the fourth month of pregnancy, and therefore abortion in the very early stages of pregnancy could be permitted. After the fourth month, however, abortion is unlawful. Abortion is only lawful in Islam where the life of the mother is at stake, as the actual life of the mother is more important than the potential life of the baby. Abortion is only performed as the lesser of two evils.

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• The special circumstances accepted by some Muslims for birth control are: –– protection of the life of the mother –– strong indications that the child would be born deformed or handicapped –– in order to prevent a woman from becoming pregnant again while she is breastfeeding a child –– personal reasons according to conscience (eg the mother may be completing a course of study). • Artificial insemination by the husband is lawful in Islam, whereas artificial insemination by donor is considered to be unlawful by the majority of scholars because it is the closest possible thing to adultery. Opinions are divided on surrogate motherhood. • Genetic experiments and genetic engineering are not permitted in Islam, because to do this is to attempt to take upon oneself the role of Allah. • Alcohol is strictly forbidden in Islam. This applies not only to wine but also to all forms of intoxicating liquor. There is one major reason for this: alcohol causes people to lose control over their own minds and bodies. Drugs such as marijuana, cocaine, opium and nicotine are also powerful intoxicants that affect the human mind and are thus also forbidden. • Although there is no mention of smoking in the Koran (which goes back to a time before the discovery of tobacco), if Islamic principles are applied, the use of tobacco should also be forbidden. Muslims believe that people should give up smoking if at all possible, and allow their bodies to be restored to health.

Specific nursing implications • Muslims will not eat pork, and meat must be slaughtered and prepared in a prescribed fashion, known as halaal. If halaal food is not available for patients, a vegetarian diet will often be acceptable, or the family can be requested to bring in food for them. • Should a Muslim patient die, he or she must be buried within 24 hours. Nursing staff should consult with the patient’s family before laying out, as the family may prefer to do this according to Muslim traditions. • Devout Muslims will not readily consent to a post-mortem examination. If a post-mortem is necessary for medico-legal reasons, however, it will be permitted provided that the deceased can still be buried within the 24-hour period. A priest or the local Islamic council will usually facilitate the carrying out of such a post-mortem within the specified period. • Some Muslims may ask to be given an amputated body part so that this can be given a burial. • Modesty is extremely important to Muslim women, and nurses must take great care never to expose patients unnecessarily.

Hinduism Hinduism is a way of life. It has no historical founder, and many sacred books are referred to. The oldest Hindu scriptures are called the Vedas, and include hymns or songs to spirits controlling nature, rules for performing sacrifice, and philosophy about 122

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the mysteries of life and death. Hindus worship one god, who has different names and appearances, both male and female. Hindus believe in the reincarnation of the soul, or atman, which passes through many lives, not all of them human. Hindus themselves call their faith Sanatana-dharma (the Universal Moral Law). Because it is universal, it is applicable to all people. The core of Hindu moral law is dharma (moral duty, responsibility), and this will vary from person to person according to age, sex, social position, education and occupation. The performance of these various duties (dharma) involves action, and actions result in karma. It is karma, good or bad, which controls the form of the Hindu’s next life. Dharma imposes three types of moral duty: to the world outside, to the immediate family, and to the self. Hindus believe that all suffering results from people’s actions. Some Hindu scriptures suggest that suffering is the result of sinful action, not only in this life but in previous ones as well. The Hindu belief in the reincarnation of the soul is based on the law of karma – the result of good and bad actions – in a previous life or lives. If a creature, whether human or animal, experiences suffering in its present existence, its karma is held responsible. Each living being is responsible for its own suffering. This law of karma can lead to a certain indifference to others’ suffering, unless it is balanced by an awareness of the unity of all creation and therefore the dharma of caring for all other living creatures. Hinduism and body matters

• Hindus believe that every human being has male and female characteristics in their personality. The dominant traits will determine that person’s sexuality, whether masculine or feminine. Hindu society and scriptures approve only of sex within marriage. Male and female homosexuality does exist in Hindu society, but both these forms of sexual expression are regarded as socially unacceptable. Heterosexuality is the only form of sexuality condoned in Hindu scriptures, and every Hindu male has a religious duty to marry and produce sons. Premarital sex is strongly discouraged. Parents watch their children carefully and, as a result, most young Hindus have no sexual experience before marriage. • Hindus have no objection to birth control on religious grounds. • Abortion is legal in India if performed in government clinics, although orthodox Hindus regard wilful abortion as one of the five great sins, the others being the killing of a learned Brahmin, drinking spirits, stealing gold, and disrespect to a teacher and his wife. • The idea of artificial insemination by a donor, however, is a difficult one for Hindus to accept. This is because of the importance of establishing a definite male ancestry for inheritance, and the need to establish caste and family background at marriage. The identity of sperm donors is unknown and this would be unacceptable to a Hindu family. • Hindu ethics raise no objections to transplants if this will save life. • Hindus also have no religious objections to the use of life-support machines. • Certain Hindu groups have long used drugs for ritual and occult purposes, and many Hindu sadhus, or holy men, still use them. Most of the commonly used drugs in India are derived from the hemp or cannabis plant. These include hashish, bhang, ganja and charus. The use of traditional drugs, in moderation, for religious rituals 123

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• •

•

•

seems to be tolerated in Hindu society. Hindu society does not, however, tolerate the use of dangerous drugs such as cocaine, heroin and acid. Smoking in the presence of elders in the family shows a lack of respect, which is not approved of. This leads to a firm control of the habit in homes. The use of alcoholic drinks in moderation is also tolerated in Hindu society, although, once again, orthodox Hindus regard the drinking of alcohol, particularly spirits, as one of the five great sins. In Hindu ethics, the taking of another person’s life is not only a crime but also a great sin. In theory, putting an end to another’s suffering by mercy killing is not acceptable. Taking one’s own life is quite another matter. Suicide was widely practised in Hindu society in India, and widows who committed suttee or sati by burning themselves on their husband’s funeral pyre were honoured for their virtue and constancy. Over the centuries, many Hindus have fasted and starved themselves to death, and this was probably the most common method of suicide. Suicide as a religious or moral act is acceptable in Hinduism.

Specific nursing implications Many Hindus are vegetarians out of respect for all forms of life, and the nurse should find out whether patients would like a vegetarian diet. If this is not available, the family may be allowed to bring food to the patient.

Buddhism Buddhism is a way of life and of understanding life based on the teachings of Siddhartha Gautama, an Indian prince, who became enlightened and left behind a system of teachings to enable others to attain the same state of enlightenment. At the heart of Buddhist teachings are the four noble truths and the eightfold path.

The four noble truths • Life is suffering. • The cause of suffering is desire. • The cessation of desire is the cessation of suffering. • The path to enlightenment is the cessation of desire.

At the heart of Buddha’s teachings in the eightfold path is the idea of not causing harm or suffering to any other being. Buddhists believe that the body they inhabit is just a temporary home. At death, the soul or subtle self leaves the body to inhabit a time and space called bardo, which is an in-between-bodies state of being. The karmic links that people have created in the past direct them to their next rebirth or new body. In Buddhist tradition, the closest parallel to pure love or compassion is the love of mothers. Buddhists meditate on the kindness of mothers in order to develop their compassion. Buddhists believe that becoming enlightened involves developing wisdom and compassion to perfection. Buddhists also believe that all sentient beings have been their mother in another life. 124

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The eightfold path • Right vows – knowing the difference between good and bad, and the effects of one’s actions • Right intentions – doing things for the right reasons without expecting reward or recognition • Right speech – non-abusive language; speaking without causing harm or offence to others • Right action – acting in a socially considerate way to others; having equanimity for all beings • Right livelihood – not earning a living through the suffering of others, for example selling alcohol or weapons or meat • Right effort – striving to perfect one’s spiritual path rather than improving material wealth • Right mindfulness – having awareness of one’s thoughts and actions so that one lives in harmony with the world • Right concentration – practising meditation to gain liberation or nirvana.

Buddhists believe that trying to satisfy our senses can cause suffering, both to us and to other people. Sex is viewed as natural, but is most rewarding within a caring and loving relationship. Sexual desire, like all desires, needs to be controlled to avoid causing suffering to others. Buddhists believe that sexual permissiveness usually results in suffering. Homosexuality is the subject of widespread prejudice in the society, but the Buddhist viewpoint is that it is important not to cause others pain, so ‘marriage’ is advised rather than the pursuit of sexual gratification. Buddhism and body matters

• The Buddha taught that life has no beginning that ordinary beings can understand. This means that whenever abortion takes place, the baby’s life form is destroyed. Abortion thus involves killing and is seen as a wrong action. • Birth control, on the other hand, actually avoids wrong action. The consciousness of the baby life form is not killed; its new body is simply prevented from forming in that particular womb. Birth control protects the partners who do not want a child from the pain of an unwanted pregnancy. It also protects the child itself from being unwanted. • Buddhists place great importance on the way in which the lifetime as a human is used, as it is only during a human rebirth that spiritual enlightenment can be reached. Buddhists are encouraged to attain and use physical wellbeing to advance their spiritual awareness. • Buddhists believe that what one does with the body affects the mind. • Drugs and alcohol are intoxicants that can affect people’s minds and induce them to think and act in ways that they normally would not. With such an altered state of mind, people can be thoughtless and careless, and therefore more likely to cause suffering to others. Buddhism therefore discourages its adherents from taking intoxicants.

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• Buddhists are encouraged to live in moderation and to avoid the extremes of living. • Most Buddhists become vegetarian because they cannot reconcile eating meat with the first precept of refraining from killing. On some holy days, Buddhists fast to divert all their attention from the body to the mind, and enable them to concentrate entirely on their spiritual practice. Fasting is usually only a temporary and shortterm measure. Generally it is viewed as an ascetic practice that does not lead to a healthy state of being. • Suicide and euthanasia are not advocated in Buddhism. Buddhism says that, because of karma, no one can escape pain and suffering through putting an end to this body. If the karma has not been fully extinguished, it will follow into a future life. • It is through the influence of Buddhist thinking that many ‘alternative’ therapists use positive thinking as part of their treatment. Buddhists say that thinking positively about their condition can only benefit a sick person. By viewing their own suffering as just one small example in the suffering of the world, individuals can gain insights in their spiritual understanding. Buddhism also teaches that the power of the mind is so great that sometimes people can actually heal themselves through meditation and concentration, although this is not a precept that is scientifically recognised.

Specific nursing implications • A vegetarian diet should be offered, or the family may be allowed to bring food for the patient. • A patient may wish to be afforded time and opportunity to meditate. If a patient is meditating, the nurse should not disturb him or her.

Traditional African Religion (Note: The following overview of African belief is not necessarily specific to South Africa, but is a general summary of the religious belief system from the whole of Africa.) Traditional African Religion refers to the indigenous religion of Africans. Africa is a vast continent consisting of many nations, cultures and languages; however, there are fundamental similarities in the religious systems which are African in nature, but religion is expressed contextually according to local culture (Beyers 2010). Accordingly, throughout Africa there is a concept of God, even though He may be called by different names, and there is also a concept of divinity and/or spirits as well as beliefs in the ancestral cult. What distinguishes Traditional African Religion from other Western religions?

Africans have a unique worldview, which is a spiritual worldview. This worldview is extremely anthropocentric in that everything is seen in terms of its relationship to humankind. • God is the ultimate expression of the existence of both humans and all things. • The spirits, which are made up of superhuman beings and the spirits of people who have died long ago, explain the destiny of humankind. The spirits also include the ancestral spirits or forefathers, who communicate with God and may be used by people to come into contact with God. 126

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• Humankind is the centre of this worldview. • The animals, plants and natural phenomena constitute the environment in which human beings live. They provide a means of existence and, if necessary, human beings may form a mystical relationship with them. African scholars in religious matters point out that this religion is an oral tradition handed down from generation to generation. It is transmitted in this way through songs, liturgies, proverbs, short sayings, myths, and others. Unlike other religions, it was not discovered by a founder as were some religions such as Buddhism, Islam and Christianity. It is strongly intertwined with the lives of Africans. Other distinguishing features of Traditional African Religion include the following: • The religion is mainly based on oral traditions – there are no written documents that support the religion. • It has no founders or reformers like Jesus Christ, the Prophet Muhammad, Buddha, etc. • It has no missionaries nor the desire to spread it everywhere (Awolalu 1976). Scholars agree that ancestors play a very important role in Traditional African Religion (Beyers 2010) in a hierarchical position that is superior to human. Ancestors are, however, inferior to God, and act as mediators between God and humans. Ancestors are particularly revered if they lived a good life and died at an advanced age after going through all the rituals, like initiation, marriage, having children and ‘dying a good death’, preferably as a result of natural causes. Accidents and suicide are not considered a ‘good death’. Meaning is always understood in a spiritual way.

Pillars of African Traditional Religion • Belief in God: This is the fundamental concept in all religious worship and every ceremony. God has creative power and is able to protect His creation. The attributes of God are often seen in the names given to children, such as ‘Goitseone Modimo’, a Setswana name meaning ‘God knows’. • Belief in divinities: These are divine beings that derive their being from the Most High. • Belief in spirits: Offerings and sacrifices are used to appease them. • Belief in ancestors: Ancestors are the spirits of the dead, especially those in one’s family who have passed on. • Belief in the practice of magic and medicine: The two can be used for good or bad purposes. Both can be used to procure what cannot be obtained in the ordinary way. When used for bad purposes, usually to harm other people, such would include witches and sorcerers, whereas medicine can be used to treat people for a variety of ailments. Methods of worship

Several practices are identified as the various forms of worship in African religion. They include prayer, invocation, blessing and salutations. • Prayer: This is the commonest form of worship. Prayers are said when there is trouble and sickness, and before taking a long journey.

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• Invocations: These are short prayers asking God to intervene in various situations. For example, if a child is missing or lost, a prayer would be something like ‘Modimo nthuse’, which in Setswana means ‘God help me’. • Blessings: These are usually given by an older person or one who has a higher status than the one receiving the blessings, for example ‘May God bless and keep you’; ‘May God go with you’; or if travelling by car on a long journey, a prayer will often go like this: ‘May God be the one driving the car.’

Specific nursing implications • Collaborate with the family as well as the pastoral care team to meet the patient’s spiritual needs. • Communicating with the patient in a language he or she understands may be beneficial for both the nurse and the patient. • A patient may request to go and ‘consult’ religious leaders before making a major decision like consenting to major surgery. • If a patient dies in hospital, the time of death is very important in order for the family to relate the time of death to specific events as reported by close relatives. This is important for the family to understand the passage of the deceased to the land of the ancestors as it is believed that one of the ancestors usually comes to take the deceased and lead him ‘where the others are’. This assists the loved ones to accept their loss and find closure. • Notifying the family members about the death of a patient should not be delayed. It is believed that any such delay may cause havoc to the surviving members of the family as the spirit of the recently deceased is in limbo and still looking for a place to reside. As soon as the family members are notified of the passing of a loved one, they should immediately bless the deceased and let go to expedite the passage to the ancestors. • A delegation of family members may visit the hospital and ask to be shown the bed or place where the patient died in order to take away his ‘spirit’ from the hospital to the family home before burial. The branch of a specific tree, called Mogaga in Setswana, is used to ‘sweep’ over the area in the ritual of ‘taking the spirit of the deceased away’. The African concept of time

The African concept of time is key to understanding the basic religious and philosophical concepts. The concept of time may help to explain beliefs, attitudes, practices and the general way of life of African peoples, not only in the traditional setting but also in the modern situation. For Africans, time is a continuum that includes events that have already occurred, events that are taking place now and events that will occur in the immediate future. What has not taken place or that which has no likelihood of immediacy belongs in the category of ‘no-time’ and does not exist. Events that are certain to occur, or those that fall into the rhythm of natural phenomena, are placed in the category of inevitable or potential time. The most significant consequence of this is that, according to traditional concepts, time is a two-dimensional phenomenon, with a long past, a present, and virtually no future. The dimension of time that is of immediate concern for the people is that of the here and now, which has the sense of immediacy, and constitutes the where

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and when of an individual’s existence. Enveloping and surrounding the here and now is a dimension of time from which the events of the here and now are created and into which these events will be reabsorbed once a certain time has passed. This is a time dimension that contains both the past and the potential events that could occur in the future. Although the idea of this second concept is not quite analogous to the Western concept of eternity, it does possess many of the features of ‘eternity’. These concepts of time are closely linked with religious beliefs in the various ethnic groups in South Africa. Human life in relation to time

Human life has a rhythm of nature that nothing can destroy. On the level of the individual, this rhythm includes birth, puberty, initiation, marriage, procreation, old age, death, entry into the community of the departed, and finally entry into the company of the spirits. It is a universal rhythm, and these are the key moments in the life of each individual. At the community or national level, there is the cycle of the seasons with their different activities. Key events or moments are given more attention than others, and religious rites or ceremonies often mark them. Unusual events or happenings that do not fit into this system, such as an eclipse, drought or the birth of twins, are generally considered to be bad omens, or at least to be events that require special attention from the community, often in the form of a religious ceremony. The abnormal or the unusual is a disruption of the harmony of the community and of the spiritual universe. As an individual gets older, he or she is in effect moving gradually from the here and now to eternity. Birth is a slow process that is only finalised long after the person is physically delivered from the mother. In many African societies, a person is not considered to be a full human being until he or she has gone through the full process of physical birth, naming ceremonies, puberty, initiation, and finally marriage and even procreation. After all that, he or she is finally born and is a complete person. Similarly, death is a process that removes a person gradually from the here and now to eternity. After physical death, individuals continue to exist in the here and now period for some time. Relatives and friends who knew them in this life remember them. They recall them by name, and they remember their personality and character, and the incidents of their life. The departed may be recognised by name for up to five generations after their death. While the departed are still remembered and recognised by name, they are not really dead, but alive and could be described as being one of the forefathers. The forefathers are people who are physically dead but who are alive in the memory of those who knew them in this life. The forefathers are also alive in the world of the spirits. For as long as the forefathers are thus remembered, they are in a state of personal immortality. African society recognises this personal immortality through actions such as respecting the departed, giving items of food to them, pouring out libations to them and carrying out instructions given by them while they lived, or when they appear, which is often in dreams. The concept of God

God is considered to be the origin and sustenance of all things. He is ‘older’ than the eternity period. He is simultaneously outside of and personally involved in His creation. He is both transcendent and immanent. God is also described as good and merciful, 129

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and He may be called upon to comfort and bless the people. For Africans, God’s love is experienced through His blessings. People experience His blessings and assume that God loves them. Manifestations of evil, such as sickness, barrenness, death or failure in undertakings, are not attributed to God’s wrath, but rather to malicious human (and occasionally spirit) agents. Manifestations of good such as health, wealth, many children and fertility are attributed to God. On the whole, God is thus not blamed for the calamities, misfortunes and sorrows that beset men and women. Spiritual beings, spirits and the forefathers

The spiritual world of Africans is densely populated with spiritual beings, spirits and the forefathers. • God has created spiritual beings or divinities in the category of the spirits. They are associated with God and His works. Spiritual beings are transcendent beings that communicate between humans and God. • Myriads of spirits are reported from every African people. These spirits are beneath the level of the spiritual beings but above the level of humans. Most African societies believe that the spirits are what remain of human beings after they die. The spirits, however, are not the same as the forefathers, who are associated with their descendants. Spirits are invisible, but may make themselves visible to human beings. Since the spirits are invisible, ubiquitous and unpredictable, the safest thing to do is to keep away from them. If the spirits, or the forefathers, appear too frequently, people feel disturbed. The spirits are then said to possess men and women, and are held responsible for forms of illness such as madness and epilepsy. Benevolent spirits exist who are responsible for the good things that happen to people. • The departed of up to five generations – the forefathers – are in a state of personal immortality and their process of dying is not yet complete. Although the forefathers maintain ties with their families, to whom they appear from time to time, usually to the oldest members, they are also part of the world of the spirits. The forefathers speak the language of the spirits and of God, to whom they are drawing closer. The forefathers are the guardians of family affairs, traditions, ethics and activities; they may warn of impending danger or rebuke those who have failed to follow their instructions. People often approach these forefathers for the minor needs of life and may also ask them for advice. For Africans, this is seen as pouring out their troubles to their seniors who have a foot in both worlds. For Africans, the spirits are a reality that must be reckoned with, whether that reality is clear or confused. Death

Death stands between the world of human beings and the world of the spirits. As death is thus an important transition, it is natural that it is marked by many, often complicated rituals and ceremonies that must be meticulously carried out. The funeral is usually a large affair, attended by all the members of the deceased’s family. A second ceremony, the purpose of which is to call back the soul of the departed to his or her own people, thus renewing the contact with the new forefathers, is often held sometime after the funeral. In South Africa this second ceremony often coincides with the unveiling of 130

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the tombstone. The rituals differ from tribe to tribe, and the purpose of the ceremonies may also differ from group to group. Magic

Belief in magic persists throughout Africa. Magic involves the use of special knowledge in order to manipulate supernatural or mystical power to achieve specified goals. Magic is categorised as being either good or evil, and is believed to involve the use of mystical power derived from the spirits and ultimately from God. Good magic brings benefits to the community such as healing, rain, good crops and fertility, and the practice of good magic is chiefly the province of the medicine man or woman, diviner and rainmaker. Evil magic involves tapping into sources of mystical power and using this power to do harm to human beings or their property. Witchcraft is the broad term used to describe all sorts of evil uses of mystical power, generally carried out in secret. In traditional African belief, disease is due to possession by spirits or a curse from a sorcerer. Suffering and illness are thus religious experiences, and their cure is seen as being largely religious, hence the importance and prominence in African society of the medicine man or woman. Suffering, misfortune, disease and accident are all ‘sent’ and to cure them the cause must be found and either counteracted, uprooted or punished. Disease, however, is not seen as being solely due to spirit possession. Africans also believe that God or the Creator, and not the spirits, cause some illnesses. Ethics and morality

As in all societies of the world, Africans value social order and peace. Among Africans, the sense of corporate life runs very deep, and the solidarity of the community must be maintained, otherwise there will be disintegration and destruction of that community. In African society there are many laws, customs, set forms of behaviour, regulations, rules, observances and taboos, which constitute the moral code and ethic of a given community. The community is also the highest moral and ethical authority as far as the individual is concerned, and the community has a duty to ensure that individuals conform and cultivate the virtues of a good character. For Africans in general, good character is shown by the following characteristics, which are highly valued in African communities: • Remaining chaste before marriage and faithful after marriage • Providing hospitality and generosity • Dispensing kindness, justice, truth and rectitude • Avoiding stealing and falsehood • Protecting the poor and weak, especially women • Giving honour and respect to older people and avoiding hypocrisy. The essence of African morality and ethics is more ‘societal’ than spiritual: it is a morality of conduct. This is what one might call dynamic ethics, rather than static ethics, for it defines what a person should do, and not how he or she should be. The medicine man or woman

To African societies, the medicine men or women are the greatest gift, and the most useful sources of help for life’s troubles. Other names for them include ‘herbalist’, ‘traditional doctor’, inyanga and sangoma. ‘Witchdoctor’ is an unfortunate Western 131

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term that is best forgotten. There is no fixed rule governing the ‘calling’ of someone to be a medicine man or woman. In South Africa it is commonly believed that the medicine man or woman has a call from the spirits of the ancestors or the forefathers. In every case, medicine men or women undergo formal or informal training. Medicine men or women are concerned with sickness, disease and misfortune, and their duties may be summarised as follows: • Medicine men and women deal with illness and misfortune, and the cure for these is both physical and spiritual. The medicine man or woman thus applies both physical and psychological remedies, which assures the sufferer that all will be well. The medicine man or woman is in effect both doctor and pastor to the patient. His or her medicines are made from plants, herbs, powders, bones, seeds, roots, juices, leaves, liquids, minerals, charcoal, and the like. In dealing with a patient, the medicine man or woman may apply massage, needles or thorns; bleed the patient; jump over the patient; or use incantations and ventriloquism; or may ask the patient to perform various actions like sacrificing a chicken or a goat, observing certain taboos, or avoiding certain foods and persons, in addition to giving the person medicine. • On the whole, the medicine man or woman gives much time and personal attention to the patient, which enables him or her to penetrate deep into the psyche of the patient. Modern hospitals deal with the physical side of illness and not much with the religious dimension of illness, which is of such importance to Africans. Many Africans will attend the clinic or hospital as well as the medicine man or woman with no sense of contradiction. So prevalent is this practice that several initiatives have been started to bring medicine men and women and Western doctors together so that they can complement each other in the treatment of patients. • Another important duty of medicine men and women is to take preventive measures. The medicine man or woman will supply countermeasures for the mystical forces that are believed to cause misfortune, illness and suffering. These may be in the form of charms, amulets, powders, rags, feathers, figures, special incantations or cuttings on the body. • Medicine men and women also give aid to increase productivity or to give good results. They advise and assist men to gain the love of women, and vice versa; they give help to men and women in high positions; they ‘treat’ people to enable them to succeed in business or politics; they supply various aids to students to enable them to pass their examinations; they perform various rites to increase the fertility and productivity of fields and livestock; they give help to barren women seeking to have a child; and they help men who are impotent. • It is also the duty of the medicine man or woman to purge witches, detect sorcery, remove curses, and control the spirits and the forefathers. Medicine men and women have access to the forces of nature and other forms of hidden knowledge, therefore the community entrusts them with the tasks of removing whatever may harm it. These beliefs are etched deeply into the psyche of African people, whether they have objective reality or not.

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Specific nursing implications • Many African patients will express the desire to consult the older members of the family, the community elders and the ancestors before making major decisions such as signing consent for surgery. Although the extent to which this can be accommodated will depend on the condition of the patient, as well as institutional policy, it may often be possible to allow for such a consultation. The patient will be much more relaxed and reassured if this wish is accommodated. • Many Africans wear protective amulets, or the family of a patient may bring an amulet with the request that the patient wears it. Provided that lines, tubes or dressings are not interfered with, this practice can be allowed and will probably reassure the patient. • The whole question of whether visits by sangomas to patients in a hospital should be allowed is a delicate one, and one that is much discussed at present. It is likely that some sort of accommodation will be reached between traditional healers and Western doctors, and programmes are already in place to bring the two together.

Conclusion Many nurses feel incapable of managing the full spectrum of their patients’ spiritual needs, especially the specifically religious dimensions of those needs, but a minimum expectation might be that a nurse should be able to provide reassurance, explanations and sympathetic attention to all patients. Should a nurse feel incapable of meeting the full spectrum of a patient’s spiritual needs, he or she should refer the patient appropriately, for example to a psychologist, psychiatrist, pastor, priest or minister of the religion to which the patient belongs. Simple religious measures that may be of enormous comfort to a patient could include reading a passage of scripture to the patient, or praying with the patient if asked and if the nurse feels able to do this. Arranging opportunities for spiritual exercise such as Holy Communion and accommodating religious beliefs and customs will also provide comfort to patients.

Suggested activities for students Activity 6.1 Answer the following multiple-choice questions by choosing the most appropriate answer/s. 1. When caring for a dying patient: a. be as quiet as possible and do not speak when providing care b. make jokes about death in order to lighten the mood c. inform relatives not to come to the hospital d. transfer the patient to a side room and leave him or her alone 2. Indicate whether the following statements are true or false: a. In order to be fair to all the patients in the ward, it is prudent not to allow any religious or spiritual practices in the ward.

➙

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b. c. d.

If a patient does not request that a specific religious leader visits him, the nurse should provide the patient with the services of the resident chaplain. Holistic care includes comprehensive nursing care that is tailored to meet the bio-psychosocial and spiritual needs of patients. Religion and spirituality are two distinct entities which are not even related.

3. Explain how you would meet the spiritual needs of patients under your care.

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chapter

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Practising nursing within a culturally diverse society

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate sensitivity towards the traditions and respect for the culture of patients and the community. • Develop effective relationships with patients, their families and significant others through culturally appropriate care and communication. • Plan healthcare, taking into account the cultural requirements of patients. • Give health information and/or health education that is culturally appropriate and acceptable to patients and their families. • Act as patients’ advocate in respect of cultural needs. • Demonstrate an understanding of the interface between Western medicine and alternative/traditional practitioners.

Key concepts and terminology Amulet: An object that is culturally considered to protect a person from trouble, such as a trinket worn to chase away evil spirits. Charms: Objects that are culturally considered to have power or a spell over evil. Culture: A way of life that encompasses the ideas, customs and social behaviour of a particular people or society. Cultural knowledge: The process in which the healthcare professional seeks and obtains a sound educational base about culturally diverse groups. Paradigm: A system of understanding and organising knowledge. Supernatural: Something that has abnormal power. Traditional practitioners: People who practise traditional medicine and have healing powers endowed upon them.

Prerequisite knowledge • Batho Pele principles • Patients’ rights • Human rights.

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Medico-legal considerations • The fulfilment of cultural requirements is a patient’s right, and failure on the part of a nurse to meet this need can be interpreted as negligence, as outlined in the scope of nursing practice, Regulation R2598 of the South African Nursing Council Act 33 of 2005. • Failure to give accurate and adequate information to patients may also be construed as negligence, particularly if they must make major decisions relating to their own healthcare, or if they will be expected to manage their own medical condition at home. In order for health information to be acceptable and understood by a patient, it must be put across in a manner that takes cultural factors into account. Failure to do this is likely to cause a patient to be non-compliant. • In situations where patients strongly wish to consult an alternative or traditional practitioner, it is imperative that they understand the full implications of their choice of such an action. • Disregard of cultural requirements is an instance of discrimination and may involve the healthcare institution, and the individual nurse, in legal action.

Key ethical considerations • Nurses have an ethical obligation to do the following: –– Respect the culture and preserve the dignity of patients at all times. –– Demonstrate that knowledge of culture and sensitivity are essential in order to avoid offending patients or discriminating against them based on their cultural backgrounds. • Every patient has the following rights: –– To participate in his or her healthcare, including having cultural needs met –– To health information and health education that is accessible, understandable, acceptable, appropriate and congruent with his or her cultural requirements –– Not to be discriminated against because he or she wishes to consult an alternative/traditional practitioner.

Introduction • Nursing is an interpersonal activity with the goal of restoring or maintaining the health of patients. Interpersonal activities such as nursing care are, by definition, built upon relationships and communication. To be effective in facilitating the healthcare of patients, nurses should develop a good nurse–patient relationship and should be able to communicate effectively with patients. It is essential for nurses to develop insight into the culture of their patients, and an understanding of how the individual patient’s culture impacts on health behaviour. This is referred to as cultural knowledge, which assists with the integration of health-related belief practices and cultural values (Campinha-Bacote 2010). Nurses must be able to gain knowledge about the culture of a patient by asking the right questions and by demonstrating sensitivity towards the patient’s beliefs and culture. Health and 136

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illness behaviour must be understood in the light of a patient’s cultural context if nurses are to fulfil their role in helping the patient to achieve or maintain optimum health. • In the light of current policy directions in South Africa, nurses may need to work with indigenous or alternative health practitioners. To do this harmoniously and effectively, nurses must develop an elementary understanding of the basic principles and philosophical outlook of these practitioners, therefore they must develop cultural competence in the delivery of alternative healthcare. Cultural competence is a set of congruent behaviours, practices, attitudes and policies that come together in a system or agency or among professionals, enabling effective work to be done in cross-cultural situations. The process of developing cultural competence includes desire, awareness, skill and knowledge (Campinha-Bacote 2010).

The concept of culture Culture is a shared set of norms, values, perceptions and social conventions that give cohesion to a group, race or community, enabling them to live together and function effectively and harmoniously. Culture is a key influence on the way an individual perceives the world and how he or she responds to it. Culture, however, is simply one set of factors among many that mould the individual and his or her response to the world and to society. Individual behaviour is heavily influenced by culture, but culture is simply a framework. Culture consists of two major aspects: • Observable phenomena, such as manner of dress, diet, architecture, language, writing and the arts • Norms and values, including how people behave, about right and wrong, and good and bad. These norms and values are usually taken for granted within a culture, and are universally accepted as being normal within that culture, having been absorbed by people at a very early age. Each individual learns about his or her own culture from an early age, and also learns how to function within that particular worldview. Culture is not inherited, but is acquired during the processes of socialisation in childhood. Subgroups or subcultures exist within every society. Organisations, occupations and professions also have their own micro-culture that individuals accept and adapt to when they join the group.

The importance of culture Culture consists of language, ideas, beliefs, customs, taboos, codes, institutions, tools, techniques, works of art, rituals, ceremonies and symbols. It has played an important role in human evolution, allowing human beings to adapt the environment to their own purposes. In a diverse society, such as South Africa, cultural differences are very evident, and to be effective in their profession, nurses must be able to work with people whose culture and traditions are different from their own, which is often difficult due to the lack of sufficient insight into their culture. Because nurses are members of a profession with the primary aim of caring for and helping people, it is vitally important 137

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for them to acquire sufficient knowledge of the cultures that they work with in order to avoid simplistic and offensive stereotyping of people. Cultural insight and knowledge are also essential for nurses from the point of view of the interpersonal nature of their work. Much of the effectiveness of nursing care is due to interpersonal interactions with the patients. Culture is therefore instrumental in communication.

The acquisition of cultural knowledge and understanding • Nurses should develop an awareness of their own cultural assumptions and prejudices. • Written or visual material on other cultures can be useful in building general knowledge, provided that such material is not biased or prejudiced. • Once a nurse has developed a good relationship with a patient, the nurse can ask questions. If the right questions are asked in a respectful manner and the response is received respectfully, much can be learned. • Nurses should not automatically assume that they know best and that their way of doing things is the only way. Nurses must allow space for the preferences of their patients, which includes, among other things, cultural and religious preferences. • Language is a powerful instrument that can be used to get to know another person’s culture.

Cultural issues in healthcare Every human society has its own particular culture. Variation among cultures is attributed to such factors as differing physical habitats and resources; and the range of possibilities inherent in areas such as language, ritual, social organisation and historical phenomena, such as the development of links with other cultures. An individual’s attitudes, values, ideas and beliefs are greatly influenced by the culture (or cultures) in which he or she lives. Culture change takes place as a result of ecological, socioeconomic, political, religious or other fundamental factors affecting a society or an individual such as acculturation, health and illness. There are several cultural factors that present as barriers to effective healthcare. Because South Africa is a diverse society, nurses need to develop an understanding of the cultural dimensions of a number of health-related issues. Many of these issues may be closely aligned to religious practices, but all need to be taken into account when dealing with patients and the community. Because nursing care is interpersonal and because nursing involves meeting the needs of patients, cultural factors such as modesty, hygiene practices, attitudes to pain and illness, diet and food, as well as death and dying must be understood and taken into account when planning nursing care. Some cultural issues are discussed below.

Diet Diet is an important cultural attribute, and it is an area that nurses must explore during the assessment of their patients, for example foods that are allowed to be eaten and foods that may not be eaten; and the method of preparation. This is important as certain African food taboos are based on cultural and religious beliefs (Kainja 2010). For example, some clans do not eat mutton because the sheep is their totem. In a hospital 138

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setting, efforts should be made to supply the appropriate diet for each patient. If the dietary requirements of inpatients cannot be met, it may be necessary to approach their families with a view to having them bring in acceptable food. A thorough knowledge of the diet of the patient, including the ways in which food is prepared, is essential when giving health education to the patient. Any health education must be contextualised according to the patient’s individual lifestyle, and this means taking careful note of specific characteristics, whether cultural or individual. In instances where health education and advice are not appropriate to a patient’s way of living and culture, the advice will simply not be followed and this will be to the detriment of the patient.

Hygiene practices Hygiene practices often differ from culture to culture. Muslims, for example, always wash their hands as well as the urethral and/or anal area after using the toilet. For some cultural groups, a bath is not regarded as hygienic, and only a shower will suffice. For other groups, specific hygiene measures are taken during menstruation. Among Hindus, the head of a newborn is shaven by one of the grandmothers for hygienic reasons. Some cultures may shave the female genital area. Nurses should take note of these and any other hygiene requirements that they encounter and try to meet the needs of their patients in the best way possible. Family hierarchy and lines of communication Family hierarchy and lines of communication are sometimes significant when consent has to be obtained for treatment or for a surgical procedure. In South Africa, the current legislation allows people 12 years and older to give consent to medical treatment autonomously, for example termination of pregnancy. However, in many African groups, consent to an operation or other form of treatment is a major decision. Sometimes a patient will ask to go home and consult the elders of the clan, and in some instances the ancestors are consulted. Many African groups require that consent for an operation on a child must be obtained from the child’s family or from a senior male relative, and the mother will feel unable to give consent without consulting the father or a male relative. This can create difficulties if the child is acutely ill and is in need of urgent treatment, and the father is not available. In such a case it may be necessary for the medical superintendent to give the go-ahead. In many groups, health matters relating to reproductive health or to sexual matters, such as contraception, must often be discussed with the husband first, before talking to both husband and wife, as it is the husband who takes decisions in the home and nothing will happen if only the wife has received the advice. It is important for the nurse to find out about lines of communication in the various cultural groups because nursing care is based upon good communication, and it is essential at all times to make sure that the lines of communication with all stakeholders are appropriate and effective. Disposal of body parts If an organ has to be removed or a limb amputated, it is essential to find out from the patient or from the relatives whether any special measures are needed for the disposal of the tissue or limb. In many cultural groups, the body parts must be given a burial and not simply sent to the incinerator. This requirement is particularly important in the case of amputation – the requirement is often not so stringent in the case of organs 139

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and parts of organs or tissues. Organ donation also varies from culture to culture, and some groups will not consent because of the belief that the deceased must be buried with all their body parts intact. Organ donation is not universally accepted among Africans, although there is no specific prohibition in traditional African belief, and this may vary depending on the particular group or set of religious beliefs. Orthodox Jews and many Muslims are also likely to refuse organ donation out of a cultural belief that the body must be buried intact, and not necessarily out of any specific religious prohibition. Similarly, Orthodox Jews and Muslims may refuse permission for a postmortem examination in line with their belief that a body is to be buried within a few hours of death.

Death, dying and the disposal of the body As this is the last thing that the family will do for the dying patient, most families have a strong desire to ensure that things are done in accordance with what the patient would have wanted. It is important to find out, for example, whether the family would like a priest to be called, as would be the case with a Roman Catholic patient. Also important would be to find out whether the family expects to be allowed to stay with the dying person and, if so, which specific family members. In the case of Jewish patients, it is customary for the family to watch at the bedside of a dying relative, but this function is also provided by Jewish community organisations that may be contacted to perform this function if the family is unable to do so. In some cultures, specific rituals are carried out at the bedside of a dying patient. The care of the body after death is also an important cultural aspect. Nurses should find out whether it is acceptable for the staff to remove tubes and lines and lay the body out, or if there is any specific procedure to be followed. An individual known as the ‘Wagter’, who is sent by the relevant Jewish community organisation, lays out a Jewish patient who has died, although it is usually expected that the nursing staff will remove the tubes and lines. Jewish and Muslim patients are accommodated in their own separate sections of the mortuary and have their own burial organisations. Amulets and charms Belief in charms and amulets is a widespread phenomenon, and is found in many cultures, even some so-called progressive cultures. Amulets and charms are believed to facilitate healing and to protect the patient from harm. The use of charms is not only found among so-called primitive groups but is found in many Western groups. Among Mediterranean groups, for example, belief in the ‘evil eye’ is common, and charms are worn to ward off the evil eye. Some amulets are religious in nature, such as a holy cross and pictures and holy medals, but their purpose remains the same: to promote healing by supernatural means and to protect the individual from harm. Generally, amulets and charms should not be removed unless this is clearly necessary, as it would be if the patient is going to theatre for an operation. It may also be necessary to remove amulets in order to facilitate treatment. If it is indeed necessary to remove an amulet, the patient and family should be informed of the need and of the reason for wanting to remove it. Sometimes amulets can be moved to other places on the body, or they can be placed at the bedside or sent home with the family, but usually the hospitalised patient prefers to keep such items close at hand. Amulets should never simply be discarded as this can cause great offence to the patient and/or family. 140

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The role of women The role and social position of women varies from society to society, and often depends on whether the society is basically matriarchal or patriarchal. In many cultures a woman is a perpetual minor, always under the guardianship and supervision of a male relative. Women in such a position usually need to consult with their husbands or senior male relatives before taking decisions, even those relating to health. Among many African groups, it is the male head of the household who must decide if a member of a household can be taken to a hospital or clinic for treatment. This often means that women must wait for absent heads of households to return before a decision can be taken. A great deal of education and empowerment is needed to change these patterns of behaviour. Sexuality Sexuality is a universal human need, but the social regulation and expression of sexuality varies from culture to culture. The area of sexuality covers relations between the sexes, modesty, rituals and practices related to the female menstrual cycle, and, very importantly for nurses, the manner in which intimate matters may be discussed. In a large number of cultures, the frank discussion of sexual matters, such as is encouraged in Western culture, is regarded as uncouth. It is common to find that it is unacceptable for sexual matters to be discussed between the sexes – women talk to women about sexuality and men talk to men. It follows, therefore, that any discussion on matters related to sexuality, such as contraception or safe sexual practices, must be approached correctly and very carefully. For some, it is necessary to discuss such matters with the head of the household, whose lead the family will follow. Depending on the group and availability, it is often prudent to have a male nurse talk to male patients or male family members, and female nurses to talk to female patients or female family members. A young unmarried female is frequently not seen as an appropriate person with whom to discuss intimate matters. The way in which intimate topics and those of a sexual nature are discussed is also important. Frank graphic descriptions are often not acceptable and may cause offence, and the nurse must find ways to get the message across using terminology that is acceptable to the patient and his or her family. Other cultural issues related to areas of cultural diversity are family organisation, language, personal space, touching, eye contact, gestures, healthcare beliefs, and spirituality and religion.

Cultural perspectives on health and illness Beliefs about health and illness are an important cultural factor in healthcare. The challenge for nurses rendering healthcare in a Western-oriented healthcare system, such as the one we have in South Africa, is to bring the health/illness paradigm of patients into alignment with the system. Health and illness beliefs fall into three major groups, described in the sections that follow.

The magico-religious paradigm In this paradigm, illness has a supernatural cause, as opposed to injury, which has a specific and obvious cause. Consequently, the cure for illness lies in the supernatural or spiritual dimension. It is widely believed among Africans that illness may be brought 141

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on by a malicious spell or by neglect or transgression against the ancestors. The cure for illness, while it may involve medication, is spiritual and involves rituals, prayer and possibly some form of sacrifice. Health may be seen as a sign of supernatural favour, and illness as a curse or punishment. In this paradigm, it is also commonly believed that the actions of one individual may affect the health of the community. Persons who adhere to this belief system do not necessarily reject Western scientific approaches to therapy, but scientific treatment methods are not seen as being the sole agent in effecting a cure. For many Africans the two systems exist in parallel, and both are regarded as being effective. For treatment within a modern scientific framework to be successful, however, patients must be allowed expression of the spiritual dimension, and access to practitioners who practise within the magico-religious framework is important. Patient education is an important factor in bringing the two systems into alignment for a patient, and the nurse is a key agent in this process. Accurate health education must be offered that takes into account the patient’s health/illness beliefs and shows respect for the patient’s own health/illness behaviours.

The biomedical paradigm This is the dominant belief system among Western cultures, but not necessarily the only one. According to this paradigm, there is a demonstrable cause-and-effect relationship for all types of illness. These causes may be due to environmental factors, trauma, pathogens, fluid and chemical imbalances or structural changes. All forms of ill health thus have a specific cause and can be cured or alleviated by eliminating or neutralising the identified cause. This belief system underpins the practice of modern medicine, but the wholeness of the individual and the relationship with the spiritual dimension are frequently lost sight of. Healthcare within a biomedical paradigm can often be experienced as dehumanising and harsh. Within this system it is the nurse who preserves a holistic approach to the patient. Nurses always strive to meet all of their patients’ needs and to ensure that all aspects of the patients’ humanity are taken into account. It is easy to become a mere technician in this model and it is important for nurses to guard against this and stand by their advocacy role. The holistic paradigm In this paradigm, human beings are seen as a part of nature. They (human beings) have a need to maintain a balance and harmony with the laws that govern the cosmos. Disturbing the cosmic balance causes imbalance, disharmony, chaos and disease. Explanations for ill health and disease are based on disharmony between the human organism and the forces of the universe. The holistic paradigm is widely held among many cultures, including Western culture. Many forms of alternative healing in both the East and the West are based on the holistic paradigm. Among Asian cultures this is the dominant paradigm. Florence Nightingale’s philosophy that the role of the nurse and the nursing profession is to provide an environment in which the patient can recover naturally reflects this holistic paradigm. This philosophy forms one of the foundations of the practice of nursing.

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Collaborative, comprehensive and/or alternative healthcare provision Patients are increasingly using alternative practitioners, and among Africans the practice of consulting a herbalist or sangoma when ill is almost universal. These two kinds of practitioner play a pivotal role in the African community. The importance of indigenous practitioners and the esteem in which they are held in the community are the basis for the frequent calls that are made for these traditional practitioners to be integrated into the healthcare system. Traditional practitioners consult the ancestors regarding the patient’s health by throwing the bones or by going into a trance. Following the diagnosis, a remedy will be prescribed, again in consultation with the ancestors. These remedies are invariably herbal and are often designed to cleanse, usually by causing purging. Other remedies are essentially tonics and vitamin preparations. Dosage and strength are imprecise and extremely variable, and some concoctions may be highly toxic if too large a dose is taken. The prescription of medication is usually accompanied by some form of ritual and/or prayer designed to enhance the treatment. Sometimes an amulet is given to the patient to complement the treatment, and should be worn until the course of treatment has been completed. Both Western and Eastern holistic practitioners may prescribe medication, again mostly herbal based. Dosages tend to be far more precise, but, again, some herbal preparations can be toxic if taken in too high a dose.

Clinical alert! It is not true that herbal medicines have no adverse effects.

In holistic practice, medication is designed to help restore the patient to a state of harmony or balance. Some alternative practitioners such as osteopaths use physical manipulation to achieve a cure by restoring the vertebral column to its correct alignment. Traditional, alternative and holistic practitioners enjoy wide respect and are frequently consulted by patients in addition to Western scientific practitioners. The problem is one of identifying a set of principles for an interrelationship between Western scientific medicine and the various forms of indigenous and alternative medicine. Often this is not a dilemma that patients will discuss with their Western scientific doctor, because the said doctor is quite likely to disapprove. Nurses are, however, quite often asked to give advice regarding the use of alternative practitioners. It is important therefore for nurses to have a sound knowledge of what treatments the various types of practitioner offer and to be able to identify those that would be harmless and those that might not be. Openness should be encouraged, and nurses should find out whether a patient has consulted a traditional or alternative practitioner and, if so, whether any form of medication is being taken. Recent dialogue with African traditional herbalists has led to the establishment of some guidelines. If the patient has consulted a traditional healer and then consulted a Western scientific practitioner, he or she should return to the herbalist to discuss this. Sometimes traditional medication can be continued, but more often it is advisable to discontinue the traditional medication until the Western medication course has been completed. In many areas of South Africa, outreach programmes and training 143

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programmes are in place to educate herbalists and sangomas regarding the interaction between traditional medicine and Western medicine. Included in such outreach programmes are principles of referral, particularly in relation to the nature of conditions that should be referred to a Western practitioner and when to do so. In the area of health education, traditional practitioners play an invaluable role. In the case of conditions such as tuberculosis (TB), it is of paramount importance that the patient continues with the treatment, whether or not traditional medication is taken in addition. Traditional practitioners are also an important link in the campaign against HIV/AIDS. It is important to convince a patient not to discontinue Western treatment simply because he or she is consulting a traditional practitioner. This principle applies particularly where regular forms of treatment such as antiretroviral therapy and dialysis are concerned, where stopping the Western treatment could be life threatening. In the case of a hospitalised patient who is acutely or even critically ill, the use of traditional medications is definitely dubious, if not actually dangerous, and should be discontinued. Once the patient has recovered, he or she can return to the herbal medicine. The problem with the vast majority of traditional herbal remedies is that they have never been scientifically analysed, and they often contain unknown ingredients that may be potentially harmful to an acutely ill patient.

A nurse’s interface with different cultures A nurse is the patient’s advocate as well as the co-ordinator of care. It is the nurse who meets the basic needs of the patient, and many of these needs must be met in a culturally appropriate manner, or at least in a way that shows respect for the patient’s culture, norms and values and does not give offence. Nurses also frequently carry a major responsibility for giving health education and of ensuring that patients and their family have understood. Nurses are thus the primary caregivers and healthcare practitioners, and they interact with many cultures. Nurses need to develop a broad store of cultural knowledge, and they also need to develop a high degree of cultural sensitivity. Cultural sensitivity embodies the principle of respect and awareness of one’s own norms and values, as well as those of the patient. Culturally sensitive nursing involves caring for a patient in a way that matches the patient’s perceptions of his or her health problems and treatment goals.

Communication in a cultural context Culture profoundly influences interpersonal communication, and it is essential for nurses to have a basic understanding of the norms and values of the cultural groups with whom they will be working in order to communicate effectively with these groups. Culture determines several key aspects of communication, such as the following: • How to greet. For example, among Africans it is not polite to get straight to the matter under discussion without first greeting the other participants and enquiring after their health. Among Africans it is the older or more senior person who is greeted, and indicates when to speak and when not to speak. In many cultures, a junior person waits to be invited to speak, or waits until the more senior people have had their say and only then may he or she speak.

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• Expressing anger and other strong emotions. In most societies, direct physical expressions of anger are not acceptable as this can be dangerous and lead to injury and even death. Showing grief is another matter. In some cultures it is a mark of love and esteem for a departed relative if those left behind cry and give way to strong overt signs of grief like screaming or tearing clothes. In other societies, control is expected on the death of a loved one. A controlled reaction does not necessarily mean that the relatives did not care for the person who has died. In other cultures, a man is not supposed to cry, or else he should cry inside without anyone noticing, whether it is about a death or some kind of pain. • Eye contact. In Western societies, looking a person directly in the eye is taken as a mark of openness and honesty. In other cultures, African culture for example, sustained direct eye contact is not polite, particularly from a junior to a senior person, or even female to male. • Gesturing and touching. Generally, areas that may be touched during communication depend on the degree of intimacy of the communicators and the context of the communication. During sexual intercourse, the partners are very intimate and all parts of the body may be touched. In normal everyday social interaction between work colleagues, there is not a high degree of intimacy, and thus only the hands, arms and shoulders may be touched during communication, especially when greeting or congratulating a person. In some cultures it is the norm to kiss the cheeks of the other person when greeting, irrespective of the gender of either person. Cultures can be categorised according to whether they are individualistic or collectivistic, as well as by their communication style. Cultures may have a high- or a low-context communication style: • Individualistic cultures, such as most Western European cultures, stress individual goals and achievements. These cultures tend to promote competition, and they place great value on achievement. • Collectivistic cultures, such as are found in Africa, stress group activities and group achievements. These place great value on co-operation and group cohesion. • Cultures characterised by a high-context communication style tend to be indirect or overly polite in communication, having a great concern for ‘face’ and leaving much to be gleaned from the context and circumstances of the communication, which means that the other person in the communication needs to possess a degree of insight into the context and circumstances of the communication in order to be able to fully understand it. Many Eastern as well as African cultures have a high-context communication style, and it can be difficult for an individual from a different cultural background to work out the full meaning of the communication unless time has been spent in developing the necessary insight to be able to communicate effectively. In African cultures, much communication is implied and the listener must pick this up from the context. Much is left unsaid or is conveyed through nonverbal means, or by riddles and euphemisms, which the listener must understand in order to grasp the full drift of the communication. For example, the expression ‘things of the blanket’ is a term used to cover a multitude of issues related to sex and sexuality.

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• In contrast, low-context cultures, such as most Western European cultures, have a direct communication style and are much more explicit verbally. The listener will know exactly what is meant, but the style is not always comfortable and can be perceived as extremely rude, especially by someone from a high-context culture. Practices to be encouraged include being aware of diversity, respecting and even celebrating it. Nurses should recognise that cultural factors are important in the health and illness of patients, and therefore ensure knowledge and respect about the cultural groups that one encounters. Recognising one’s own biases, prejudices and blind spots, and working to overcome them when dealing with patients will assist in finding ways to care for patients in culturally appropriate and acceptable ways.

Nursing implications • Ignorance and lack of understanding of other cultural groups should be addressed. • Stereotyping such as assuming that all individuals belonging to a particular cultural group conform to a general pattern or behave in a certain way should be avoided. Remember, all patients are individuals and their behaviour and reactions are also determined by other factors, such as family, education, state of health and environment, and not just culture. • Judging other groups by one’s own norms and values should be avoided. Certain basic principles, such as the concern for hygiene, are practically universal, but may be expressed in different ways. • Assigning negative attributes or characteristics to persons from another cultural group should not be done. • Seeing the worldview and experience of other groups as being inferior should not be done. This insidious habit leads to prejudice, discrimination and racism. • Taking a paternalistic attitude of ‘I know what’s good for you’ is demeaning and should be avoided. • Being culturally blind and proceeding as though cultural differences do not exist should be avoided. The practice of giving dietary advice that is based exclusively on a typical Western diet is an example.

A nurse’s role within the multidisciplinary team from a cultural perspective It is not possible for the average nurse to undertake an in-depth study of every culture that he or she encounters. Certain key aspects, however, are important in healthcare and these should be assessed as part of a routine nursing assessment. These are the following: • Diet and food habits • Rituals and taboos relating to key events in the lifecycle, such as sexuality, birth and death • Health and illness beliefs • Types of practitioner consulted • Health/illness behaviours and decision making, including family or clan involvement • Relationship with health professionals, as in many cultures the medical practitioner is expected to tell the patient what is wrong, and not the other way round 146

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• Genetically based biological variations, such as blood values, bone structure and density • Practices related to modesty • The discussion of sensitive issues.

Conclusion The importance of culture in communication cannot be overemphasised. It is in communicating that both the nurse and the patient come to experience each other’s cultures – that is, the language, mannerisms, attitudes, judgements, customs, rituals, way of doing things, etc. It is essential for nurses to develop a basic insight into the culture of all the patients that they deal with. Failure to develop this insight will hamper healthy communication, and nurses without this insight may be seen as being insensitive or even rude as a result of their lack of understanding of the culture of the patient. Where language is a problem, translators may be useful. It is also important for nurses to use the correct channel of communication, such as a senior male relative when necessary, and to use communication as a tool to learn patients’ culture for effective nursing care.

Suggested activities for students Activity 7.1 A patient in your unit is confused and refuses oxygen therapy, saying it is disturbing him as he would like to communicate with his ancestors. He becomes violent when you try to put the face mask on him. He then requests you to give him space to discuss the treatment (oxygen therapy) you want to give him with his great-grandmother, who is already dead. • What do you make of the above statement? Do you think the confusion manifested is an indication of poor oxygen perfusion, especially in the brain? How does this behaviour enhance or inhibit the achievement of the specific outcomes outlined in this chapter? • Describe how a nurse can provide culturally competent nursing care.

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chapter

8

Community assessment

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate an understanding and application of the following terms to community assessment: –– demography; epidemiology; rate; incidence; prevalence. • Demonstrate competence in doing a demographic and epidemiological profile of the community. • Demonstrate competence in doing action research as a mechanism for community assessment. • Interpret demographic and epidemiological data collected while doing a community profile. • Make a community diagnosis based on the needs of the community.

Key concepts and terminology Artefacts: Historic objects kept as evidence of practice. Assessment: A process of evaluating an aspect. Cohort: A group of people who share a certain characteristic(s) or experience(s), and are tracked over a period of time. Demography: The scientific study of the characteristics of human population groups in terms of size, growth, composition, structure and distribution. This includes biodata (biostatistics of births, deaths or diseases). Epidemiology: The study of the factors that determine and influence the frequency, distribution and causes of disease, injury and other health-related conditions and events in specified population groups for the purpose of establishing programmes to prevent and control their occurrence and spread, and also to evaluate the effectiveness of such healthcare programmes. Incidence: The rate at which new cases of infections occur in a population in a specified period of time. Indicator: A measure that helps quantify achievement of a goal in monitoring and evaluating the performance of programmes, for example mortality, health behaviour and morbidity. Morbidity: The impact of disease in terms of sequelae or complications.

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Mortality: Death rate in a community. Prevalence: The proportion of a population found to have a condition in a total number of people studied (expressed as a fraction, percentage or number).

Prerequisite knowledge Students should have knowledge of the following: • Basic research methodology • Social sciences.

Risks • Consultation with community members who are not the key informants. The result is faulty planning leading to fruitless and wasteful expenditure as well as compromised service delivery. • Information that is biased.

Key ethical considerations There must be a thorough and accurate assessment of community needs: • Comprehensive but ethical attention must be given to each need with due respect to the community as an entity. • The ethical protection of human dignity, especially in specific vulnerable groups within the community is vital. • The nurse has a moral obligation to fulfil the advocacy role in the community.

Essential health literacy It is the responsibility of the nurse to educate the wider community on health issues, therefore campaigns on health promotion are mandatory. These would include aspects of primary, secondary and tertiary prevention.

Introduction Community assessment is a means through which a nurse develops an awareness of the community, its nature and characteristics. It is the first phase in the healthplanning process where information on the current strengths, concerns or problems – actual, potential and possible – are identified and put into perspective with and by the community. Plans to solve the problems or meet the needs, and the actions to be taken, are decided upon in a collaborative manner so that the process is owned by all involved. Community assessment focuses on local assets, resources, activities in and outside the community as well as gaps, barriers and emerging needs. 149

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Nurses will be introduced to the process and, at this early stage, they have to develop skills in research so that the assessment is done systematically and scientifically.

The meaning of community A community plays an important role in determining a person’s state of health and health behaviour. For example, the dynamics of daily living activities in rural communities are different from those of urban communities. These impact on the state of wellbeing as well as the behaviour of the people in the community. The demographics in these communities are also very different. Despite these differences, a right to health is one of the basic human rights of all persons, and this right is comparable to life and freedom of movement, speech and association. The most important component in a community is its people who, in a defined place and time, form a social unit. The people in a community share elements of common life, such as spatial arrangements, institutions, interaction, day-to-day activities, interests, history, heritage, values, beliefs, norms and power structure, even though they may be culturally diverse. As a part of a larger society, a community can be described in terms of its population characteristics, which include age, sex, race, ethnic origin, kinship and relations, income and educational level. As a social organisation, a community can be defined within geographical boundaries. These facilitate administration, planning and allocation of resources, as well as social control.

Definition of a community A community has the following components: • People • Environment/place • Resources and services • Social systems in terms of relationships.

The meaning of community assessment Community assessment is a mechanism or process through which an understanding of a community is crystallised as it identifies and describes attributes of its components, their patterns and organisation. It provides a means of establishing geographical and social boundaries of a community, its strengths, and any actual and potential problems. Through it, gaps and inequities in resource allocation and administration and groups at risk are identified. The purpose of community assessment is to obtain relevant information about the people in the community to ensure that a community’s needs, inclusive of health needs, are correctly and fully assessed and that the best policies are developed to meet them, and also to empower the people in the community by involving them in the identification of problems and the planning of interventions devised by them. In this regard, community assessment will assist in the following: • Identifying community needs in general and in particular in terms of vulnerable groups • Identifying cultural differences in relation to interests, concerns and motivation 150

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• Analysing processes through which a community’s beliefs, values and attitudes are transmitted • Identifying mechanisms that can best be utilised to involve the community in the process • Developing community-specific interventions that are acceptable to the community. Community assessment relates to the systematic collection of data so as to be informed about the community at hand. The data may come from a variety of sources, such as the environment, patients, families, local municipal records and/or nurses’ observations. Data can also take different forms. Demographic data

The word ‘demography’ is derived from two Greek words – demo meaning ‘people’, and graphos meaning ‘writing’. Demography is defined as the study of populations with respect to their distribution in terms of size, density, age, sex, race, ethnicity, births, deaths, socio-economic status, marriage, divorce, structure, composition, migration and any changes in a given period of time. In community assessment, demographic characteristics may affect health outcomes directly or indirectly. Demographic characteristics also give direction on the adequacy of facilities in relation to the sharing of capacity. For example, knowing the number of children under five years of age in a community would assist in informing health planners on the number, type and location of services to be provided. Similarly, the number of births would give an indication of the fertility rate of the community, enabling planners to forecast population growth. Statistical expressions used to manipulate demographic data are rate, ratio and proportion. A rate expresses a mathematical relationship between the people and disease occurrences, in which the numerator is the number of persons experiencing an occurrence of a health problem/disease/condition, and the denominator is the population at risk of developing a health problem/disease/condition. It is therefore a measure of the number of people who suffer from a health problem/disease/condition in a given period of time in a given number of people living in the same area at the same time of the occurrence of the health problem/disease/condition.

Rate =

Number of people suffering from the health problem/disease/ condition in a specified time period Population at risk during the time period under consideration

×

1 000 1

An example of a rate is the infant mortality rate (IMR): this is the number of infant deaths (death before the age of one year) during the year divided by the number of live births (infants born alive) during the same year. A ratio is any number divided by any other number. For example, sex ratio is the number of males per 100 females, or vice versa. A proportion is a special type of ratio. It is obtained by dividing the given number of people who suffer from a health problem/disease/condition by the total population. For example, the proportion of males in a community would be obtained by dividing the given number of males by the total population (both males and females).

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X (males) Proportion =  X + Y (males and females)

Similarly, the proportion of people who die from lung cancer will be obtained by dividing the actual number of lung cancer deaths by the total number of the population. Epidemiological data

The term ‘epidemiology’ is derived from three Greek words, epi, meaning ‘upon’; demos, meaning ‘people’; and logos, meaning ‘study/thought/science’. It is a branch of medical science that deals with the incidence, distribution and control of disease in a population, and it encompasses concepts from demography and research. Epidemiology is the study of the distribution pattern and determinants of health and disease frequencies in human populations for the purposes of promoting wellness and preventing and limiting disease occurrence. Epidemiology describes diseases that occur in groups of people (not individuals) at a time, known as epidemics. These are investigated and conclusions are drawn about the distribution pattern in relation to who or which group of people in terms of age, sex, race, ethnicity, etc. suffers from the disease; where these people live; how often they suffer from the disease, such as every year, month or week (frequency); at what time of the year they suffer from this disease (winter, summer, etc); and, in some instances, why they suffer from that particular disease or have that risk factor. It is by observing these large groups of people and analysing their characteristics that commonalities and differences among those who do or do not have a particular disease can be identified. In this way, predisposing factors and possible causes can be predicted. The distribution and determinants of health and disease can further be explained in terms of an epidemiological triad. This triad consists of the host, the agent and the environment, which interact in a specific manner to allow for disease occurrence. The triad explains and describes who gets the disease, what causes it, and under which circumstances and where it will occur, and why. The triad also relates to the person, place and time. In the triad, the host usually refers to the organism or people who host or accommodate the agent such that the disease process can occur. The host can also be described as people who are susceptible to the disease depending on their genetic makeup, immunity, nutritional state, cultural practices, lifestyle and/or health status. The agent is the causative factor, and may be biological, chemical or physical in nature. The effect of the agent depends on its strength (virulence), pathogenicity, infectivity, duration of exposure of the host to it, and the place where host and agent meet. The environment usually complements or inhibits the activities of the agent by either providing conducive conditions to thrive or by inhibiting progress. The environment refers to all external factors that influence and contribute to the vulnerability of the host. The factors can be physical (climate, temperature, food supply), socio-economic (social forces, resources, support systems, culture, work, education) and biological in nature (immunity). Apart from rate, ratios and proportions, other terms associated with epidemiology are morbidity and mortality. Morbidity relates to illness and disease, while mortality relates to death. The terms are used to measure states of health in a community. 152

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Morbidity statistics are indicated by the following: • Attack rate: This measures the proportion of the population that develops a disease to the total number of people exposed to a specific risk over a specified time. • Incidence rate: This is the number of people in a community who develop a disease/ condition (new infections) during a period of time. The determination of incidence requires that a population be followed over a period of time in what is known as a prospective study. • Prevalence rate: This refers to the number of people in a community who have the disease/condition (existing cases of a disease – old and new) at a point in time. Prevalence is a product of incidence, and health planners use prevalence to provide for treatment of a condition and hospital beds. Incidence and prevalence rates are traditional measurements necessary for appropriate assessment of community health. Mortality refers to deaths in the community in a given period. The mortality rate measures the number of reported deaths in a community per 1 000 population in a given time. The death rate in a community can be indicated either in general (the crude mortality rate or total number of deaths in a community regardless of cause and person affected) or in specific (the specific mortality rate or death in a specific population group and/or its cause) for accuracy and meaningfulness. The specific mortality rate is in accordance with events like age-specific mortality rates, cause-specific mortality rates, race- and sex-specific rates or case fatality rates. In community assessment, it is important to know the impact of disease and illness as indicated in the incidence and prevalence rates of diseases as well as mortality rates. To a nurse these are indicative of the needs in the community.

Research and community assessment ‘Research’ is a term used when a systematic and scientific investigation or inquiry into an aspect or a problem-solving process is undertaken. Research in the community does not focus on extremely rare health conditions, unless these are expected to affect the health of society as a whole. For an aspect to be researchable, there should be a perceived discrepancy between the ideal and the actual situation, or lack of information about a phenomenon, an organisation or a community.

Warning! Research involves empirically demonstrable findings, not value judgements. Issues of morality and ethics cannot be researched. For example, research cannot determine whether termination of pregnancy is morally or ethically good or bad.

Research follows specific steps: • Definition of the problem or interest area • Review of literature • Formulation of a hypothesis • Aim or purpose of the research

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• Objectives of the research • Research methodology: –– Setting/place/location where research is done –– Selection of a research design –– Identification of the population to be studied –– Selection of a sample through sampling techniques –– Selection or development of data-collecting instruments and procedures –– Pre-testing of data-collecting instruments –– Data collection –– Ethical considerations in research –– Data analysis and interpretation of results –– Research report and dissemination of results. The steps help researchers to keep focus.

Participatory and action research Research can take many forms. In community assessment, however, demographic and epidemiological principles are used in the research process, and participatory and action research are the recommended approaches to access accurate information. Participatory research encourages active participation of the people whom the research is intended to assist. Participatory research places emphasis on different ways of knowing beyond scientific ways, such as intuition and general experience. The use of focus groups, in-depth interviews and participatory observation to collect data empowers the participants and allows them to be engaged in the research process. Action research demands that the researcher and the community work as equal partners in the planning and implementation of the research project. Furthermore, action research is dynamic as activities are determined by need, and partners learn from each other – the researcher provides academic scientific skills to the project while the community provides first-hand practical information/experience on the problems and resources available. Ethical obligations include ensuring representivity of the community, and responsibility, commitment and accountability of the researcher without prejudice. Definition of a problem

Within the parameters of participatory and action research, definition of a problem in a community mandates the involvement of the community through its representatives who have a good understanding of the extent of the problems and the people’s concern in this regard. It is also important for the representatives to understand the extent to which underlying causes of the problems have been explored, including means and resources available to solve the problems. This is because in many instances, identifying the problem does not automatically imply that its causes are understood or solutions are immediately at hand. Literature review

Research tends to focus on the present. Since a community’s current characteristics are a result of the past, finding out more about the community is always necessary. A literature review in this instance may mean getting information from people by word of 154

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mouth or through written text. How long has the problem existed? What is the history behind it? What are its characteristics? What has been done in the past to address the issue? Who were or are the people concerned and what are their concerns? It may also mean relying on observations made in the community in relation to the environment, people’s attitude and people’s mood. Literate communities would have written reports in this regard. Reviewing literature is also important to get other perspectives from other places and people on the issue. A critical review of literature is usually the sole responsibility of the researcher because he or she would have access to the library and other literature sources. Information about the problem would also determine whether the problem exists or not, and whether it is researchable or not. Hypothesis

A hypothesis helps in giving direction to the research project as it narrows the investigation scope. A hypothesis makes assumptions on solutions, and predicts the outcome of the research project. The predictions have to be proved in the research. A hypothesis is a statement by the researcher to express his or her expectations concerning the outcome of the research. Care is to be taken in community research not to dictate terms (guided by a hypothesis) in an effort to conduct research that will yield results quickly. Research methodology

Research methodology is the overall plan of the research process starting with the research setting and the design. The design is determined by the purpose of the research, as well as resources available. There are experimental designs where the researcher introduces some form of intervention, and non-experimental designs where data is collected without trying to provide for intervention. In non-experimental designs, the purpose is usually to explore, describe, explain, identify or evaluate a phenomenon. Non-experimental designs are especially desirable when epidemiological principles are applied, and studies can either be prospective or retrospective.

Remember the terms: incidence and prevalence • A prospective study begins with a group of people, known as the cohort, who have been exposed to a particular event, disease or condition. The group or cohort is the population at risk of developing the disease or condition by virtue of proximity to it. In the study the cohort is followed over a period of time to measure how many people in this cohort did or did not develop the disease in that given period of time (incidence rate). • A retrospective study is a backward look in time to determine risk factors and potential causes of a disease or condition. For instance, for lung cancer sufferers (prevalence) a history of their lifestyle may reveal reasons for their affliction. A retrospective study is sometimes referred to as a case-control study, where a cohort (group of people who have been exposed to a disease/condition) is compared to a control group (a group of people who have not been exposed to the disease or condition) to see the group’s ability to develop or not develop the disease or condition in question.

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Population and sample

The population to be studied encompasses the people at risk or the unit of analysis. The studied population can be broken into manageable portions, called a sample. The sample/portion is a subset of the population and must be representative of the whole. Caution must be exercised to ensure that the selection of a sample is not biased and is as random as possible. Research instruments

To collect data an instrument must be developed to ensure that questions asked are regulated to be the same for every participant. Instruments used in community assessment are usually interview schedules, protocols, questionnaires and existing records like census data. These may be augmented by observations made in the environment including artefacts. The instruments must be tested for validity (to see if they really measure what they are meant to measure) and reliability (to see if they are consistent in their measurement). This is known as pre-testing the instruments. Ethics and informed consent

Ethical consideration in research is very important as it ensures that the people or subjects to be researched are agreeable to the study, and the process is in line with the requirements for the protection of human rights. Permission to do research must be sought before the study commences. Failure to do this may be seen as violation of the government’s Constitution on human rights. In research, the information received must be treated as confidential, and participants should not be penalised for information they give or for participation in the project. Participants must be informed of what the research is about and they must give consent to allow for their involvement in the research or refusal to participate. This is known as informed consent. Data collection, analysis and interpretation

Data collection must follow a precise method. It must be specific and within the parameters of the design. Data analysis and interpretation must be done soon after data collection while information is still fresh in the mind of the researcher. A concise but explicit report must be written and results disseminated to the relevant people who need to use the results of the study. Research skills are necessary in community assessment as the nurse, in collaboration with the community, has to collect meaningful data that will be analysed to identify needs and actual and potential problems in the community. To do this, the nurse may need to live in the community for the period, interviewing diverse community members and participating in community life. Data collected in this period would be regarded as primary data. Living in the community will assist in integrating the nurse into the community, making him or her more acceptable to the people. The use of focus groups would be a better option for ensuring community participation. Using these groups would also provide for generating innovative solutions to chronic problems.

Process of community assessment As indicated earlier, community assessment is a process through which the nurse collects information about the community to become acquainted with that community. 156

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The principles of the nursing process (assessment, diagnosis, planning, intervention and evaluation) are followed. According to the principles of participatory and action research, the people in the community and the researcher are equal partners and should contribute throughout the process. The aim of community assessment is to identify factors (both positive and negative) that impinge on the health of the people in order to develop (a) policies; and (b) intervention strategies for better health.

Steps in community assessment Step 1: Identification of the community

In assessment, the community must be identified by name within identified geographical as well as social boundaries. Boundaries can also be political or natural. In some instances, a community can be identified within a community in terms of activities and vulnerability. Political boundaries are usually those assigned by government for administration and allocation of resources. Natural boundaries are those determined by nature and spontaneous occupancy, such as mountains, rivers, roads on which villages are established following natural availability of land and accessibility, and sometimes natural resources like water and pastures. The boundaries, whether political or otherwise, usually become locally internalised and recognised with time, so much so that local customs may impact on them. Social boundaries relate to normative systems that dictate how people live and relate in a given area. The social boundaries within a binding culture build solidarity among members of the community and provide a sense of belonging. People who share a culture need not be geographically related; the feeling of belonging sustains the relationship and association with specific communities, regardless of distance. In identifying the community, it is also important to assess other geographical and physical characteristics occurring within the boundaries, such as climate, vegetation and terrain, and whether the community is urban or rural in nature. For example, some diseases are determined by climate (eg respiratory infections are more pronounced in cold weather than in warm weather), while other diseases may be related to vegetation (eg asthma is rife in areas with a high pollen content). Other related aspects include the following: • Potential artificial and natural disasters, such as flooding, cyclones and drought • Potential accidents in homes, roads and industry • The terrain that would assist in the planning for communication and physical mobility in the community • Urban communities have different dynamics in comparison with rural communities. In urban areas, facilities are also more readily available and utilised much more than they are in rural areas. • The presence of vectors such as mosquitoes, flies and rats plays a role in the spread of disease. • Housing conditions often reflect the socio-economic status of the community and predispose occupants to disease and accidents or protect them against these. For example, informal settlements are indicative of instability, overcrowding, lack of privacy and home accidents. • Sanitation and safe water supply are important aspects in determining health in a community. 157

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• Issues of pollution in relation to air, soil and water are very important and are usually determined by conditions of sanitation. The data for the above information would be collected by accessing maps to the area, talking to the people and environmental officers, and making observations as the nurse travels through the community. There may be a need to review available records and read literature about the area and its related health problems in line with those found in other similarly situated areas. Step 2: Demographic data

These data will include information about the population, its size, density, distribution and composition in terms of age, sex, race, ethnicity, socio-economic status, residence (urban vs rural) and vulnerability in terms of groups at risk such as the aged, infants and adolescents; and events such as births, deaths, marriages and divorce. The information collected may reflect genetic features, family compositions (extended, polygamous or nuclear), relationships, race-specific diseases, customs, values, norms, beliefs and religion of the people. Population changes as evidenced by births, deaths and migration may place extreme demands on the provision of services to the point where there may be a need to revisit the operating health plans to compare current products and services to needs. Population changes would also have an impact on the size, distribution and density of people in given areas (urban and rural). This would in turn have an impact on the causes of illness, and the availability, operation and provision of the relevant services. The educational level is related to skills, employment and civilisation, and therefore the economy of the country. Communities with high unemployment rates have low educational levels with poor skills and low productivity. The lifestyles of people in these communities are usually poverty-stricken, leading to poor health. Diseases and healthrelated problems in these communities include alcoholism, substance abuse, nutritional disorders, communicable diseases and other diseases related to poverty. It is also important to identify the social and political organisations in the community in order to establish the formal order system, the leaders and other stakeholders not necessarily in the leadership. The culture of the people would be as important as their political affiliations and governmental jurisdiction, which should be democratic. Knowledge of human population distribution will assist in the prediction of potential and possible needs in relation to service provision. This information would be obtained through a review of statistical data and records in the form of registers, diaries, minutes of meetings, newspapers and magazines, tapes and videos, and through conducting interviews with people, as well as making the necessary observations. Step 3: Epidemiological data

These data would include information about the health of the people in general and groups at risk in particular. The disease profile should be categorised in terms of the demographics of the community so as to be able to establish those most affected and why they are affected. Diseases affecting children should be categorised according to developmental stages. Infants would need well-baby services as well as services for ill children (maternal and child health services); children aged between one and four 158

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years would need services for minor ailments as well as immunisation, crèches and preschool services; children from five years of age would also need school health services. Services for adolescents, the aged and the working community would be provided under the categories of age as well as groups at risk. Family planning and reproductive services for both sexes should be available to address issues of fertility. Together with the assessment of disease distribution, there should be the assessment of facilities which may be used to address the issues or lack of facilities that may in actual fact contribute to the causation of the disease or conditions. These would include the following: • Communication, transportation and safety factors. The data would include the mode that people would use to get around, such as buses, taxis, trains, bicycles, aeroplanes, boats, horses, carts and even commuting on foot. Aspects of availability and affordability should be considered, as well as the condition of footpaths, roads and bridges, railway tracks, canals and waterways, harbours, airports, and the like. Where possible, the distance of health services from people’s residences should also be considered. The recommendation from the World Health Organization is that services should be 8 km walking distance in rural areas and 5 km in urban areas. For availability and affordability of communication, postal mail and telephones should be considered. Other communication means are television, radio, newspaper, magazines, meetings and minutes. Many rural areas would not have access to newspapers and electronic media, but they would have access to radio, through which they would be able to conduct better and well-organised meetings. • Safety and protection. The issue of safety includes the location and activities of the police or other means of protection, such as neighbourhood watches, street committees and community policing forums, to protect the people, their belongings and environment. • Hospitals and clinics. These should be considered in terms of classification (private vs public, or primary, secondary or tertiary level) numbers, their distribution or location, their accessibility and the services they provide. These would also be assessed in relation to population size, composition, distribution and needs, as well as administrative mechanisms that make access possible and affordable. Related to this would be the assessment of personnel to serve the people in the services. Statistics of health professionals and ancillary assistants, including personnel from other related sectors, should be reviewed. • Schools. It is important to assess the number of schools and the grades they provide for and proximity to residences to enable every child to be educated, so that illiteracy is kept at a minimum in the community. The numbers of pupils who enrol and remain at school should also be assessed to avoid overcrowding and ensure maximum benefit for everyone. At tertiary level, availability of universities and universities of technology offering a variety of degree and diploma programmes should be assessed. Additional data to be collected are the availability of teachers, school enrolment, the dropout rate, and achievement at primary, secondary and tertiary level. • Employment opportunities. These will be determined by the number of industries as well as by the skills available in the community. This will also complement the information on education above. 159

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• General supplies, including grocery stores, hardware stores and fuel stations. These may affect the health of the community depending on what they provide and the cost involved. The grocery store may provide food items that are nutritious, such as milk, bread, vegetables, fruit and meat, or introduce food fads like polished rice, fizzy drinks and fast foods. • Religion. This is an important attribute as it provides for the spiritual needs of a community. Churches may provide for these needs, as well as individual beliefs as in the case of traditional healers with their many forms of therapy modes. • Recreational and sporting facilities. These allow for exercise and maximum relaxation for all age groups, for example play areas for children, parks, games/ sports stadiums, swimming pools, gymnasia and libraries. The type, attendance, utilisation, interest of children and commitment of teachers are to be assessed.

Practical tips in community assessment • Make a tour of the community within the identified boundaries to get a feel of the place. • Take photographs, and make slides and videos of the place during your travels. • Talk to the people informally and formally. • Make appointments with people you need to see and interview. • Always state the reason for the appointment so that the person you want to see is prepared. • Attend community meetings to learn about the community. • Always have an action plan. • Be objective, and document all findings immediately.

Community diagnosis The community diagnosis is a statement that describes all the issues, problems and needs identified during the community assessment, as well as related factors contributing to them. It is based on conclusions made once the data have been collected. The summary of these conclusions include the following: • The strengths of the community. These include existing facilities that can be used or adapted to address the identified issues, as well as the community’s willingness to participate. • The weaknesses of the community are those in relation to gaps in information, shortages in facilities, poor management structures and unwillingness to relate to other structures, and unwillingness to participate in the processes. • Opportunities open to the community to improve its situation include the availability of assistance, as in the case of outsiders who are willing to provide for development projects, and the community’s potential and ability to make an input in the solutions of problems and needs, though lacking the necessary knowledge and skills. • The threats that may hamper action directed at interventions include political instability, crime and climatic variations.

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A meaningful community diagnosis can only be made once data collected have been analysed as a whole to reflect the actual situation. To determine the intensity of the issues, the actual situation as revealed in the assessment is compared with the ideal as indicated in the literature or experiences in other communities. Having identified the issues, problems and needs, as well as the community’s strengths and shortcomings in meeting the needs, the nurse must, in collaboration with the community, prioritise the needs. He or she must note that what may appear to be an issue from his or her perspective may not necessarily be a priority with the community. The criteria for setting priorities are the following: • The degree of concern about the identified problems or needs • The severity of the threat posed by the problems or needs • The extent to which the problem can be resolved with minimum upheavals in the community.

Interventions Planning Having prioritised the problems and needs, and completed the diagnosis phase, the planning with the community begins, based on available resources and stated objectives. The plan must fit into the community’s agenda – that is, politics and power structure. The objectives must clearly state milestones to be achieved in the short- and long-term periods. The objectives must be realistic and congruent with specific community needs, and must indicate how change will be effected and expected to impact on the problems experienced. Implementation Once the planning has been completed, these plans need to be implemented. The community should carry this out with expert assistance, and the nurse may facilitate this. As this may mean changing habits, the nurse must prepare the community for managing the change, and introduce it in phases. Aspects critical for success include the following: • Effective communication with an open approach that will limit resistance and suspicion • Meaningful negotiations between the professionals and the community • Consistent respect of each other’s views, values, beliefs and culture.

Evaluation The process of community assessment must be evaluated at each stage. Evaluation is the determination of the worth of something. It involves the reviewing of every activity undertaken in terms of achievements. Did the assessment achieve what it was meant to achieve? Have all aspects been investigated? Is the information well presented (that is, in such a way that it is meaningful to all stakeholders)? Has the diagnosis taken into account all the identified issues? Is the plan simple? Are the objectives attainable? Are planned and implemented interventions addressing the issues identified? 161

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The evaluation in its intense form will determine whether the goals and objectives have been met

Conclusion • Assessing community needs is a very important step in health provision, one that cannot be left to chance. No health plans can take place without full information about the people to be provided for. Data collected and analysed in community assessment provide a database that serves as a reference point now and in the future. The evaluation of performances and the development of performance indicators, whether national or regional, are done against these original data. Due to the complexity of the task, many other sectors have to be consulted. Data collected can also be used in other service-providing departments.

Suggested activities for students Activity 8.1 The month of June was noted for the admission of diarrhoea sufferers. The afternoon of 10 June saw 15 people presenting with diarrhoea being treated and admitted in the medical outpatients department of the local hospital. On history taking, it was noted that the patients came from the same area, and that many people in the village were suffering from diarrhoea in varying degrees. The people, it seems, get their water supply from a nearby river that never runs dry, even in winter months. The river provides households as well as animals with water. The river runs over a long distance from the Drakensberg mountain range. The diarrhoea outbreak in this village is said to be cholera related. Interpret this paragraph in epidemiological terms.

Activity 8.2 Community assessment is a complex undertaking that is also time consuming, but due to its importance it has to be done if an effective and efficient healthcare service is to be provided for the people. Develop a data-collection instrument for community assessment AND in the next recess/vacation, as your term assignment, collect data about the community you come from and present this when the recess/vacation ends.

NB: The lecturer can take these data and use them for teaching data coding and analysis in senior classes.

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Learning objectives On completion of this chapter, the student should be able to do the following: • Accurately and comprehensively assess a patient in order to identify needs, monitor responses to treatment and identify further problems and/or complications. • Develop approaches to assessment that are quick, efficient and that take all relevant factors into account. • Accurately validate assessment findings. • Develop assessment guidelines and instruments that are quick and comprehensive, for use by staff in a variety of clinical practice areas. • Keep records related to assessment and assessment findings. • Adjust assessment protocols and instruments in order to facilitate the individualised assessment of every patient.

Key concepts and terminology Activities of daily living: Routine activities carried out by the patient in the course of each day. Assessment: Gathering information about a patient or response to treatment. Closed question: Type of question that is put in such a way that only a ‘Yes/No’ response is obtained. Culture: Placing tissue or body fluid in a growth medium to determine if any bacterial growth takes place, indicating infection. Cyanosis: The blue discolouration of the skin as a result of decreased oxygen uptake in the blood, usually a sign of respiratory insufficiency. Demographic information: Information pertaining to the social, cultural, religious and economic circumstances of the patient. Empathy: The ability to identify with or understand and share the feelings of another person. Health history: Information pertaining to past illnesses, injuries and surgical procedures. Inspection: Looking at the patient to detect significant signs related to the patient’s health problem. Interview: A structured conversation with the patient or the patient’s family for the purpose of gathering information.

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Jaundice: Yellow discolouration of the skin as a result of increased circulating bile pigments where the red blood cells are destroyed in large numbers, usually a sign denoting poor liver function. Leading question: Type of question that is put in such a way that the answer is suggested to the patient. Measurement: Assessment of specific physiological parameters. Monitoring: Specific readings and measurements taken to determine the patient’s response to treatment on an ongoing basis. Objective data: Information revealed by examination. Observation: Looking at the patient to detect significant signs related to the patient’s health problem. Open-ended question: Type of question that is put in such a way as to obtain an opinion or description. Patient history: Record of the patient’s experiences, specific problems that have caused him or her to seek treatment, past illnesses/injuries, lifestyle, work and family circumstances. Petechiae: Capillary bleeding into the skin. Signs: Specific findings related to the patient’s health problem as revealed by the examination. Subjective data: Information given by the patient. Symptoms: Specific events, sensations or incapacity experienced by the patient and described to the nurse. Vital signs: Specific physiological parameters that give a general indication of the state of a patient’s health and give a broad picture of physiological function.

Prerequisite knowledge The nurse must have knowledge of the following: • An understanding of the basic principles of nursing care and their application in nursing practice • A basic understanding of the professional and legal framework of nursing in South Africa • A basic understanding of the ethical framework of nursing • An understanding of the bio-psychosocial needs of the patient • An understanding of the importance of religious beliefs and cultural background in the care of patients.

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Medico-legal considerations • Failure to thoroughly assess an individual may lead to problems being overlooked. • This could result in inadequate care, or the development of complications. • Failure to monitor a patient’s progress and to assess on an ongoing basis constitutes negligence. • The scope of practice directs nurses to assess each patient fully, identify all needs and problems, and then draw up a nursing regimen for the patient. • The incorrect labelling of specimens may lead to the wrong results being recorded for the patient. As changes in treatment are frequently based on laboratory results, this type of error could have very serious consequences. • It must be borne in mind that the results of certain tests, such as those for HIV or sexually transmitted disease, are strictly confidential.

Key ethical considerations • Every patient must be individually assessed, from a nursing as well as a medical point of view, in order to identify all possible needs and problems. Failure to carry out a thorough assessment constitutes disregard of the patient’s right to accurate assessment and full care of his or her problems. • Full and accurate assessment is an important facet of the nurses’ professional obligation to patients. • When carrying out an assessment, a nurse should never make assumptions that are based on stereotypes about the patient. The patient should always be approached as a unique individual who has needs that are specific to him or her. • All information obtained by the nurse during assessment of the patient is to be regarded as confidential and not to be divulged to anyone other than the patient’s medical practitioner.

Introduction Accurate and comprehensive assessment of the needs of patients is a prerequisite for the planning of effective and holistic nursing care. Assessment is the initial step in the planning of care. It is the first phase of the nursing process and requires a systematic approach, in which priorities are correctly identified and acted upon. The assessment procedure must be adapted to the needs and conditions of patients. Ongoing assessment is also necessary to determine the patient’s responses to care, as well as to identify further problems or complications. During assessment the patient must be treated as an individual, and the nurse must be able to deal appropriately with each patient’s unique personality, reactions and circumstances.

Reasons for patient assessment Assessment is an essential initial step in the nursing process, allowing for planning and decision making with regard to patient care. Assessment is an ongoing process, 165

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enabling the nurse to determine progress. Assessment, both initial and ongoing, should give a complete picture of a patient’s needs and problems, allowing for holistic care and an individualised approach to the patient. The accountability of nurses makes thorough assessment mandatory. The regulations of the South African Nursing Council reflect patient assessment and identification of needs as a professional obligation, and failure to meet this obligation may lead to disciplinary action. Nurses are also expected to monitor each patient’s response to treatment and to keep the patient’s medical practitioner informed about developments. None of these obligations can be fulfilled without assessment. Assessment can be viewed as initial and ongoing. Initial assessment takes place when the patient is first seen, and ongoing assessment takes place during the course of treatment in order to monitor the patient’s response and to identify further problems or complications. Table 9.1  Activities related to initial and ongoing assessment Initial assessment

Ongoing assessment

Full history

Observation

General physical examination

Specific physical examination

Diagnostic tests

Selected diagnostic tests

Assessing a patient Taking a patient’s history A good history is a record of a patient’s experiences, not only of specific problems that have caused him or her to seek care but also of past illnesses and health problems in general. A good history will provide the nurse with essential information regarding a patient’s lifestyle and work, as well as family circumstances. The history will also provide valuable clues about a patient’s values, attitudes, opinions and fears, as well as his or her level of knowledge and understanding of matters related to health.

Purposes of history taking History taking provides subjective information as the patient gives it by explaining or describing his or her experiences. A patient’s history is taken in order to establish the following: • The essential facts about the patient’s health problems, as experienced by the patient • The attitudes and beliefs of the patient regarding his or her health problems • The patient’s life circumstances and family/community relations and interactions.

Approach to the patient during history taking The taking of the history during the assessment of a patient is often the patient’s first extended interaction with members of the health team and, from a nursing point of view, it is an important starting point for the development of a caring and constructive nurse–patient relationship. It is essential to approach the task of history taking in 166

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such a way that the patient’s confidence in the health team is enhanced. The patient may ask questions about the nurse’s professional experience, religion, as well as his or her marital status and value system in order to establish whether the nurse can be trusted with personal or sensitive matters. Adult patients are often reluctant to entrust personal information to a nurse whom they may view as young and inexperienced (especially if the nurse is not married) and the nurse will have to break through this barrier using empathy and a professional approach. History taking is done by means of a structured interview that is designed to elicit the required information from the patient in a systematic fashion. The interview

The following are important factors during an interview with a patient: • Courtesy and attentiveness are important, as well as a supportive attitude, which will communicate genuine interest in the patient and his or her problems. • The nurse’s manner and behaviour should be professional, and he or she should take care to ensure that personal appearance, manner and approach will inspire confidence. Anything that could be offensive should be avoided. • Nurses should show sensitivity and awareness of possible fears and feelings on the part of the patient. • When beginning the history taking, the nurse introduces him- or herself to the patient and explains the purpose of the interview. • The nurse should explain the relevance of the questions posed, as this might not necessarily be apparent to the patient. • The nurse should also provide an assurance that all information will be kept confidential. • The nurse should make sure that the patient’s name and title are accurately recorded and correctly spelt. Patients should always be addressed by their correct name and title. The inappropriate use of nicknames or casual modes of address may be offensive to a patient. • The setting in which the interview takes place should be comfortable and relaxed. • The nurse should ensure the privacy of the patient and orientate him or her to the environment. Noise and interruptions should be kept to a minimum. • The interview should be logical and follow a format that is designed to cover the essential areas of the history. • As far as possible, the set sequence of the interview should be adhered to. If the patient is not sticking to the point, or is given to very long-winded or circular explanations, the nurse should gently refocus the interview by bringing the patient back to the question at hand. • During the interview, a well-judged combination of information-gathering techniques is used to obtain as complete a picture as possible. The specific techniques used will depend on the patient, the circumstances and the amount and type of information needed, as in the examples below: –– Closed questions are used to obtain a specific ‘Yes/No’ response. Example: ‘Are you short of breath?’ –– Statements are used to obtain subjective information about something that the nurse has noticed. Example: ‘I see that you use a walking stick.’ 167

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•

• •

•

•

–– Repetition can be used to clarify or restate something said by the patient in order to ensure accuracy. Example: ‘You said that you become short of breath if you “do too much”.’ –– Open-ended questions are used to obtain the patient’s own opinion or description. Example: ‘What is the pain like?’ –– Reflection, restating the patient’s response in the same words, is used to encourage the patient to provide more detail on a specific point. Example: ‘You say it’s a “gripping pain”.’ –– Interpretation, restating the patient’s information in the nurse’s own words, is also used to clarify and validate information. Example: ‘The pain must have been quite bad if it made you stop what you were doing and sit down.’ –– Summarising is used to sum up and check information already obtained. Example: ‘When you got up this morning, you felt dizzy, then you “blacked out”.’ –– Occasionally confrontation is necessary if the nurse’s observations do not correlate with the information obtained from the patient. Example: ‘You say you are not short of breath, yet you had to catch your breath after undressing to get into the hospital bed?’ –– As a rule, the nurse should avoid asking leading questions, or questions that suggest a symptom to the patient. Example: ‘Do you have a squeezing pain in your chest?’ The technique used depends on the type of information to be obtained. Excessive use of open-ended questions could result in a long, rambling and inconclusive history, whereas too many closed questions could suggest symptoms to the patient. The nurse should avoid asking more than one question at a time: multiple questions may confuse the patient and prolong the interview. The nurse should also avoid the use of confrontational questions, or questions that can be interpreted as being confrontational. The words ‘why’ and ‘why not’, for instance, can sound hostile. During the interview the nurse should continuously observe the patient and be aware of his or her reactions. Eye contact, body language and facial expression may all give important clues to problems. The nurse should, however, always validate or check non-verbal cues received from the patient. The manner in which responses are made may also be significant: anxiety-provoking facts may be camouflaged by a joke or a casual manner; evasiveness may indicate a sensitive topic; something about which the patient is very worried may be repeated several times; significant information is often given at the start or conclusion of the interview.

Special circumstances

• The condition of the patient. A patient’s condition, or the general circumstances of the assessment, may necessitate changes in the way in which the history is obtained. For example, patients who are critically ill, semi-conscious, unconscious or confused are unable to give a coherent history, and should not be subjected to an attempted interview. In these circumstances, the nurse may have to be content with obtaining a few essential facts from the patient, the family, bystanders or ambulance personnel. A more complete history can be taken later from the family 168

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or from the patient, provided he or she has recovered sufficiently to participate in a full interview. • Elderly patients. Such patients require patience and attention to detail during history taking, and the nurse should bear the following in mind: –– Listen carefully to the patient and be prepared to take time over the interview. The elderly frequently have slowed cognitive responses which do not, however, necessarily imply that they are mentally impaired. Some prompting and focusing of questions may be needed. –– Elderly patients frequently have sensory deficits, such as poor vision and hearing, and the nurse should adapt the interviewing technique accordingly. Memory may also be impaired. –– Acute illness in the elderly frequently presents atypically and with non-specific manifestations, such as incontinence, confusion, immobility and falls. Elderly patients often accept these problems as part of the normal process of ageing, and consequently they may not always be mentioned. The nurse should specifically ask the patient or the family about this type of manifestation. –– When starting the interview, the nurse should come to some conclusion about the patient’s mental state by asking simple questions, such as the day or the year, or recalling recent events in the news. The nurse should explain the reason for these questions – that is, to see how the patient’s memory is. Many elderly patients, while not actually senile or delirious, can become very disorientated and muddled when asked a series of questions, particularly if the environment is unfamiliar. –– The nurse should take the interview slowly, be prepared to repeat and rephrase questions as necessary, reassure the patient, and orientate the patient to the surroundings. Encourage the patient to stick to the main thread of the interview. –– Elderly patients frequently suffer from multiple and chronic disorders in addition to the main complaint, and the nurse should ask about cardiac problems, respiratory problems, hypertension and arthritis, to name a few of the more common ones. Multiple medications are also common, and the nurse should try to find out about all of the drugs the patient is taking. • Children. The extent to which children participate in the interview depends on their age, but even very young children can contribute, provided they are able to speak and answer simple questions. Usually, however, it is the parents of very young children who give the bulk of the information, but older children and teenagers may prefer not to have their parents present. When interviewing a child, the nurse should speak clearly and directly without being condescending. Be patient and friendly, and avoid statements or questions that may frighten the child.

The physical examination Once a patient’s history has been taken, the nurse will carry out a physical examination in order to collect objective data about the patient. Objective data are information that is elicited by observation and examination, as opposed to information that is given by the patient, which is subjective. The history tells the nurse what the patient’s symptoms are, whereas the examination reveals signs related to the patient’s health problems. 169

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The principal features of the general physical assessment are as follows: • Ascertain the patient’s name, age and sex. • Carry out a general inspection of the patient. • Take vital signs. • Carry out a systematic physical assessment.

Approach to the patient Nurses should take the following approach when examining a patient: • Ensure privacy for the examination. Keep exposure of the patient’s body to a minimum, and expose only what is absolutely necessary. • Explain the procedure to the patient. • Make sure the patient is comfortable. • Continue to build on the relationship of trust that was established during the history taking. Talk to the patient, constantly reassuring him or her, and explain the steps of the examination. In some instances, it may be necessary to inform the patient about the findings thereof (eg ‘Yes, I feel a lump here’). • Continue to ask questions during the examination. Findings on examination may suggest further questions related to body systems. Do not, however, alarm the patient by asking pointed questions about a body system while examining that system as the patient may jump to the conclusion that something is wrong.

Critically/acutely ill patients In the case of critically ill patients, carry out an abbreviated physical examination that focuses only on the essential aspects of the patient’s illness and general physical condition. A full physical examination can be done once the patient’s condition has stabilised. A full examination may exhaust a patient who is acutely ill, and as little time as possible should be wasted between assessment and the commencement of treatment.

Techniques used during the physical examination Please refer to Chapter 2 of Juta’s Manual of Nursing, Volume 2: The practical manual. Inspection or observation

Inspection involves looking at, or observing, the patient. The process of observation is not, however, a cursory one, but it is a focused and purposeful top-to-toe survey of the patient using the senses of vision, hearing and smell. Inspection begins with a general survey of the client as a whole, followed by an inspection of each area or part of the body. When doing so, first note the general appearance of that part, followed by a more detailed observation of size, shape, colour, texture and movement. The two sides of the body should be assessed for symmetry.

General inspection of the patient General state of health • Note whether the patient appears to be generally well or unwell.

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• Note signs of distress, pain and dyspnoea on first encounter, as these problems will require immediate attention. • Note the general mental state of the patient, including signs of anxiety, agitation, confusion, withdrawal, aggression or other inappropriate mental state. Build and general nutritional state • Note whether the patient is well nourished, overweight or obese, or thin and malnourished in appearance. • Note the build of the patient – whether stocky, muscular, slender, petite or lanky. • Note the patient’s physical and sexual development. Are they appropriate for his or her age? General appearance of the patient • Note the way in which the patient is dressed, as well as grooming and hygiene. • Note whether the patient is dressed appropriately: are his or her clothes worn correctly, or are they mismatched or incorrectly put on or are they in line with the temperature of the day? Bizarre or inappropriate dress may to some extent be a matter of personal taste and eccentricity, but odd combinations and incorrectly worn items may indicate an altered mental state or a visual deficit. • Note general appearance, facial expression, skin colour, eye contact and manner of speech. Posture and gait • Note the position as well as the manner in which the patient holds him- or herself. Does the patient walk and hold him- or herself in an easy relaxed manner, or is the patient tense? Is the patient’s posture stooped or upright? • Note any spastic, convulsive or abnormal movements, as well as the manner, speed and ease with which the patient walks. • Note symmetry of movement as well as any tremors. Palpation

Palpation means examination of the body by means of touch. Palpation enables the examiner to determine certain aspects relating to the condition of the patient’s tissues and organs. Aspects that can be determined by palpation include swelling, stiffness, movement, outline, crepitations, spasm, the presence of masses, enlargement, texture, tenderness, temperature, shape and the presence of fluid. For palpation to be effective, the patient should be relaxed as tension may interfere with the results. To relax the abdominal muscles, the patient can be asked to lie on his or her back with the legs bent at the knees. Breathing deeply and rhythmically while in this position will also help. The examiner’s hands should be warm, and he or she should work gently. • Light palpation. The examiner uses the tips of the fingers and palpates to a depth of 1–2 cm, using gentle pressure, with the hand held parallel to the part being palpated and the fingers outstretched. Muscle tone and rigidity can be felt by this method, as well as slight tenderness.

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• Deep palpation. This technique uses more pressure than light palpation. The palm of the hand is placed on the part to be palpated: with the fingers extended, the area is palpated to a depth of 3–4 cm. This type of palpation is used particularly for the abdomen: deep palpation of the abdomen causes the underlying organs to move beneath the fingertips, making it possible to feel the position of organs such as the liver and spleen, as well as the presence of abdominal masses. The technique of deep palpation can also be used to check for rebound tenderness. The area of the abdomen is first palpated deeply and slowly, and then the hand is quickly removed. Rebound tenderness is present if the sudden removal of the hand causes pain. The presence of rebound tenderness can be confirmed by comparing the reaction of the client when adjacent areas are palpated. • Bimanual palpation. For bimanual palpation, the palm of the other hand is placed on the palpating hand. The pressure is exerted by the upper hand, while the lower hand is relaxed, allowing for palpation of deeper organs and/or masses. Bimanual palpation may also be used to overcome the resistance presented by tense muscles or a thick layer of abdominal fat. • Ballottement. Ballottement, or quick palpation, involves a light, bouncing movement, keeping the fingertips in contact with the abdominal wall throughout. Masses that are freely moveable can be more effectively felt with this technique than by standard palpation, which may push these masses away. Percussion

Percussion means to strike or tap. This technique involves light tapping on the surface of the body and analysing the sounds that are thus produced. The sounds vary with the density or solidity of the organ being percussed. Percussion is used to determine the amount of fluid, air and/or solid matter in the lungs or abdomen, and can also be used to determine the size, position and borders of the other thoracic organs. Percussion is also used to test reflexes by tapping specific points on the body using a patella hammer or other suitable object. Although a dull sound is produced, it is the evocation of the reflex response that is important, and thus this is not considered to be a pure percussion technique. • Indirect percussion. This is carried out by placing the middle finger of one hand on the surface to be percussed, and tapping the first (distal) inter-phalangeal joint with the middle finger of the other hand. Only the middle finger of the lower hand should rest on the surface of the body. • Direct percussion. Direct percussion is done by directly tapping on the surface to be percussed using one or two fingers of one hand. • Fist percussion. Fist percussion involves using the side of a clenched fist to tap on the upper surface of the other hand, which is placed flat on the body. Fist percussion is usually used on the lower back to check for pain due to renal, urinary or gall bladder problems.

Sounds produced by percussion Percussion sounds may be hollow, or dull and flat. Hollow sounds are described as resonant and they are produced by air-filled structures, such as the lungs. • Normal lung tissue emits a clear, low-pitched resonant note.

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• Hyper-inflated lungs emit a loud drum-like, high-pitched note described as hyperresonant. • A drum-like sound, known as tympany, is characteristically produced by the presence of air in hollow viscera such as the stomach and intestines. Dull percussion sounds are produced by solid tissue, or by the presence of fluid in hollow or air-filled structures. Muscle tissue produces an absolutely flat ‘thud’. Auscultation

Auscultation means to listen. This technique is used to listen directly to the sounds made by the movement of air or fluid in the body. Auscultation is used to assess the movement of air in the lungs, the movement of blood in the blood vessels and the movement of digestive fluids in the gastro-intestinal tract. Direct auscultation involves placing the ear directly on the part that is to be auscultated and listening directly. Indirect auscultation involves placing a stethoscope or some other form of amplification device onto the surface in order to screen out adventitious sounds and to amplify those sounds made by the organ that is being auscultated. Measurement

Measurement involves the determination of specific physiological parameters that give a general indication of the state of a patient’s health, and provide a broad picture of physiological function. Also known as vital signs, these measurements are standard observations that form part of every physical examination. They consist of the following: • Temperature • Pulse • Respiration • Blood pressure. The vital signs give a basic indication of a patient’s cardiac and respiratory function, as well as body temperature. Vital signs are taken initially and at regular intervals in order to assess progress. Other measurements of function that may be carried out include the following: • Lung function tests • Testing of reflexes • Measurement of intraocular pressure • Testing of visual and auditory function.

Diagnostic tests The final element in the assessment of a patient comprises specific diagnostic tests that are designed to amplify information gathered during the physical assessment, and to provide more detailed information about the patient’s health status. The role of the nurse is as follows: • Explain the procedure to the patient, and obtain consent if necessary. • Prepare the patient pre-procedure. • Carry out appropriate and correct aftercare post-procedure. 173

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Measurement of electrical activity The function of those tissues and organs that show electrical activity can be assessed by recording this electrical activity by means of electrodes placed on the surface of the body: • Electrocardiography measures the electrical activity of the heart. • Electroencephalography measures the electrical activity of the brain. • Electromyelography measures the electrical activity of skeletal muscles. Visualisation techniques These techniques allow for the visualisation and examination of the interior of the body using an endoscope. Tissue specimens or biopsies may also be taken at the same time for laboratory examination. Endoscopy may allow for direct or indirect visualisation of the structure under investigation. Direct visualisation takes place using an eyepiece and a light source attached to the endoscope. Indirect visualisation occurs by means of video images or photographs taken via the endoscope. Endoscopes, and the procedures carried out with them, take their names from the body part to be examined. For example, the bronchoscope is an endoscope used for visualisation of the bronchi, and a bronchoscopy is an endoscopic examination of the bronchi using a bronchoscope.

Guidelines for systematic physical assessment Cardiovascular system • Observe the patient’s colour, and condition of the skin and fingernails. • Palpate all major pulses, apex beat and heart rhythm. • Auscultate heart sounds and basal crepitations in the lungs. • Measure pulse rate, blood pressure and central venous pressure. Common findings may include the following: • Cyanosis; clubbing of fingers; raised jugular venous pressure; peripheral oedema • Distended neck veins • Hepatomegaly (enlarged liver) • Splenomegaly (enlarged spleen) • Abnormal heart rhythm • High or low blood pressure. Respiratory system • Observe the patient’s colour as well as the rate, depth and rhythm of breathing, dyspnoea, cyanosis, clubbing of the fingers, use of accessory muscles, cough, type and amount of sputum, shape of the chest, and symmetry of movement during breathing. • Palpate the position of the trachea, and for tactile vocal fremitus. • Percuss each lobe of the lungs in the same position on either side of the chest. • Auscultate breath sounds and air entry in the base and apex of both lungs, listen for adventitious sounds and vascular bruits, and for vocal fremitus. • Measure respiratory rate. ➙

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Common findings may include the following: • Dyspnoea and shortness of breath; use of accessory muscles; uneven movements of the chest during respiration • Sputum production • Cough • Chest pain, which may or may not be associated with coughing. Gastrointestinal system • Observe the condition of the lips, mouth, teeth, gums and tongue; note any jaundice; note the size of the abdomen; inspect the skin of the abdomen; inspect the anus. • Palpate all areas of the abdomen; determine the lower border of the liver. • Percuss the area of the liver. • Auscultate bowel sounds: note additional sounds, such as vascular bruits. Common findings may include the following: • Alterations in eating patterns • Vomiting and/or diarrhoea • Alteration in elimination pattern • Abdominal pain and/or cramping • Distension of the abdomen; excessive wind or flatus • Presence of blood in the vomitus or faeces. Urinary system • Observe for general oedema; note the appearance of the urine. • Do a bimanual palpation of both kidneys; palpate the urinary bladder. • Measure the specific gravity and the chemical constituents of the urine. Common findings may include the following: • Abnormalities on urine testing • Difficulty in passing urine; retention of urine • Incontinence • Pain on micturition. Central nervous system Assessment of the central nervous system consists of the evaluation of specific responses and functions: • Mental state • Gross and fine motor function • Reflexes • Cranial nerve function • Sensory function • Level of consciousness, including Glasgow coma scale. Common findings may include the following: • Altered level of consciousness • Altered mental state; behavioural changes; disorientation and/or confusion

➙

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• Muscle weakness; abnormal movements; exaggerated or depressed reflexes; altered pupil reflex; convulsions • Altered or abnormal sensation and sensory function. Musculoskeletal system • Observe for deformity and swollen joints. • Palpate for tenderness of muscles and joints; assess the extent of any swelling. • Assess movement at the joints, and assess the normal function of each joint. Common findings may include the following: • Pain and/or numbness, or a tingling sensation • Deformity and/or swelling • Joint swelling and limited movement; immobility • Sensory changes. Reproductive system • Observe for discharges and genital lesions. • Palpate the scrotum in males. Common findings may include the following: • In female patients: menstrual irregularities; vaginal discharge; pelvic pain; lumps in the breast; nipple discharge; lesions of the vulva and/or vagina • In male patients: difficulties in micturition; swelling of the scrotum; lesions of the penis and scrotum. Integumentary system • Observe for skin lesions. • Palpate the texture of the skin; palpate for oedema. Common findings may include the following: • Skin lesions; rashes; redness; swelling; abnormal dryness of the skin. Haematological/reticulo-endothelial system • Observe for evidence of abnormal bleeding. • Palpate size of spleen; palpate for any enlarged lymph nodes. Common findings may include the following: • Bruising; petechiae; swelling; jaundice • Enlarged or painful lymph nodes.

Radiographic techniques X-rays penetrate the organs and tissues of the body and, depending on the type of tissue, will be absorbed at varying rates. This variable absorption of X-rays by the organs and tissues is due to the different densities of the tissues. When X-rays are passed through the body onto a photographic plate, an image is created in which the internal structures of the body are seen as shadows of varying density. To enhance the image of soft tissues, which all tend to be of the same density, various contrast media can be used:

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• Iodine and barium absorb more X-rays and make the outlined structure appear more dense and solid. • Air and carbon dioxide absorb fewer X-rays and make the structure appear as a dark, hollow outline. Contrast media may be introduced in various ways: orally, rectally, intravenously, into the sub-arachnoid space, or into the bronchial tree via endotracheal tube or bronchoscope. Fluoroscopy, or screening, involves projecting the X-ray image onto a fluorescent screen. This enables the examiner to view the passage of a contrast medium through a structure. Fluoroscopy also allows the accurate positioning of invasive monitoring and intravenous lines that have built-in radio-opaque strips or markers. Still pictures can be taken as needed during fluoroscopy. Common fluoroscopic examinations include the following: • Intravenous pyelography • Angiography • Cholangiography • Barium studies of the GIT • Myelography • Mammography.

Nuclear techniques Nuclear techniques involve the use of radioactive isotopes. These isotopes have an affinity for specific tissues (eg radioactive iodine has an affinity for thyroid tissue), and these tissues absorb the isotopes. The amount of isotope that has been absorbed can be detected by a scanning device, resulting in a picture that shows the degree of activity of the various parts of the organ or tissue under study. The more active the tissue is, the greater the amount of isotope that is absorbed. This type of scanning can also be used to detect tumours, which are usually more active than the surrounding normal tissues. Tomography This technique is also known as computerised tomography (CT scanning). The technique involves passing a narrow beam of X-rays through sequential ‘slices’ or planes of the part of the body that is to be studied. A radiation detector detects unabsorbed X-rays that emerge after passing through the tissue. These data are fed into a computer that builds up a picture of the cut, showing areas of high density as white areas and areas of low density as dark areas, with many gradations of density in between. CT scanning is useful in detecting minor differences in density, giving a clear picture of the organ or tissue under study, and facilitating the detection of tumours, cysts and haematomas, which have specific density characteristics. CT scanning provides a three-dimensional view in that the cuts can be viewed from all three planes, but the images produced are all two-dimensional. A contrast medium is frequently used to enhance the picture. Ultrasonography This technique involves passing ultra-high-frequency sound waves, which are not audible to the human ear, through the body. These sound waves are reflected back by the tissues according to their density: highly dense tissue such as bone reflects sound 177

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waves well, whereas soft tissue and air-filled structures such as the lung are poor reflectors of sound. The sound echoes obtained by this technique are translated into a display unit for visualisation: what is seen is a picture of the depth of a structure beneath the skin, allowing the antero-posterior dimension to be determined. The depth and dimension of masses can be determined using this technique.

Magnetic resonance imaging Magnetic resonance imaging (MRI) produces three-dimensional images without using radiation. The part to be examined is placed in a magnetic field, and the atomic nuclei in the magnetic field are stimulated. These emit measurable radio signals, which are detected and converted to a visual display.

Laboratory studies A number of tests are carried out on body fluids and tissues in the laboratory in order to establish or confirm a diagnosis (see Table 9.2). Table 9.2  Common laboratory studies Microscopy

This refers to the examination of tissue/fluid under a microscope

Culture

The fluid or tissue is placed in a growth medium to see if any bacteria can be cultured from the specimen

Chemistry

This involves the determination of the chemical (organic and inorganic) composition of body fluids. Chemistry testing will include estimations of mineral salts, electrolytes, proteins, enzymes, fats and sugars, among other things

Histology

This refers to the examination of tissue to determine the type and number of cells present and whether they are normal or abnormal

Haematology

This refers to the examination of the blood – the number and type of blood cells are determined, as well as their normality or abnormality

Common diagnostic tests Routine tests are fundamental to the general assessment of the patient and are taken on admission and as needed thereafter: • Ward urine tests • Blood tests: chemistry; haemoglobin; full blood count; blood glucose • Plain chest X-ray • Electrocardiogram • Further specific tests will depend on the problems identified during the initial assessment of the patient.

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Conclusion Patient assessment is very important in that it is the first interaction and conversation that the patient has with the health professionals. This interaction is often a new experience for the patient, and is usually intense and anxiety provoking, sometimes involving difficult decisions to be made in the company of people hardly known to the patient. The approach of the nurse usually makes a lasting impression. The history taking must be non-threatening, and the nurse–patient relationship has to be conducive to building trust so that the patient will open up and provide valuable information. The nurse can then make nursing diagnoses and design a care plan that responds to the patient’s needs.

Suggested activities for students Activity 9.1 Use Juta’s Manual of Nursing: Volume 2: The practical manual, as a reference. Mrs N’s present complaints are a productive cough that she has had for two weeks, fever and loss of appetite. • Describe the physical examination that you will carry out on Mrs N that will enable you to identify all her needs and state other additional subjective and objective information that should be obtained from her to support your identified needs. • The exercise should include the correct use of a stethoscope, correct forms for recording the findings, and correct recording of findings. NB! Consider the rights of the patient and the nurse, as well as the ethical and legal aspects of the whole process.

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chapter

10

Planning nursing care

Learning objectives On completion of this chapter, the student should be able to the following: • Define ‘planning’ as applied to the nursing process. • State the purpose of the planning of nursing care. • Describe the activities involved in the planning of nursing care. • Identify the characteristics of a good care plan. • Formulate expected outcomes for a nursing diagnosis. • Draw nursing care plans for use by everyone who is involved with the care of the patient. • Describe validation of nursing care plans. • Explain the requirements for effective implementation of a care plan. • Describe the evaluation of a care plan. • Explain the principles to be applied in record keeping in nursing care plans.

Key concepts and terminology Collaborative nursing interventions: A partnership in which all members of the health team are valued for their contribution in the care of patients. Dependent nursing interventions: Nursing interventions based on the prescription of care from another health professional. Discharge plan: Planning for the needs of the patient after discharge from the hospital. It is a future-oriented plan. Expected outcome: A detailed statement describing the desired result following implementation of intervention methods. Goal: An aim, intent or an end – a broadly written statement describing the intended or desired change in the patient’s behaviour or condition. Initial planning: The first plan of care drawn out on admission or when the patient is first admitted into a health facility. It includes a comprehensive subjective and objective assessment regimen to be able to identify the patient’s actual, potential and possible problems. Nurse-initiated or independent nursing interventions: Nursing actions initiated by the nurse that do not require direction or an order from another healthcare professional. ➙

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Nursing care plan: An outline of actions to be taken in the care of individual patients to address identified individualised patients’ problems. Nursing interventions: Nursing activities which are directed at enabling the patient to meet his or her needs and achieve the expected outcomes of care. Ongoing planning: Continuous updating of the client’s plan of care. Every nurse who cares for the patient is involved in ongoing planning. As new information about the patient is gathered and evaluated, revisions may be formulated, and the initial plan of care becomes further individualised.

Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy and physiology • Basic nursing skills.

Medico-legal considerations • According to the law, nurses will be guilty of malpractice (omission) if they fail to assess a patient thoroughly as this may lead to problems being overlooked, possibly resulting in inadequate care or the development of complications. These situations can be avoided by: –– initiating proper treatment –– summoning medical help when there is need to do so –– intervening to protect the patient –– implementing patient teaching. • Failure to monitor a patient’s progress and to assess on an ongoing basis constitutes negligence. • The scope of practice directs nurses to assess each patient fully, identify all needs and problems, and then draw up a nursing regimen for them.

Ethical considerations • Informed consent should be obtained before data collection and before any decision is made regarding the design of a care plan as well as implementation of nursing interventions. Written consent is required before some invasive diagnostic studies are carried out. • Nurses are obliged to ensure confidentiality of the information collected from the patient throughout the application of the nursing process. • The patient’s right to information should be respected at all times. All steps of the nursing process should be explained to the patient. ➙

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• In accordance with the South African Patients’ Rights Charter, the patients must be allowed to exercise their right to privacy, dignity and second opinion; to refuse treatment; and to participate in their own care and decision making. Patients should be involved in the plan of care based upon their ability to participate in and make decisions regarding care. • The right to safety is also stated in the Charter, therefore nurses are morally and legally obliged to provide nursing care that is safe, ethical, holistic and accountable. This includes: –– transparency and integrity with regard to the nursing regimen –– peer review and validation of nursing actions and care plans –– interprofessional validation of nursing actions and care plans within the multidisciplinary team –– the use of correct methods and a scientific approach in the provision of nursing care.

Essential health literacy Health education aspects communicated to patients should enable them to participate in their own nursing care and encourage self-care.

Introduction The nursing process is a systematic approach to nursing that involves interaction with each patient to assess needs and problems, make decisions regarding the resolution of the patient’s needs and problems, and implement the planned nursing actions based on the assessed needs and problems. It is a scientific process and a step-by-step method of creating holistic, individualised care for each patient. Fundamental to the nursing process are the principles of assessing and identifying unmet patient needs, and of specifying nursing interventions to meet each one. The main steps or phases of the nursing process include assessment, diagnosis, planning, implementation and evaluation. Recording is an integral part of the nursing process and is carried out in every phase of the nursing process. The focus of this chapter is the planning of nursing care, the implementation of nursing interventions and the evaluation of nursing care plans. The steps that precede planning are assessment and formulation of diagnoses, which were discussed in detail in the previous chapter (Chapter 9). Nurses will be introduced to written care plans, their implementation and evaluation. Discussion on the use of care plans as an ongoing record of continuous nursing care is also included in this chapter.

Planning nursing care A plan is a method or proposed course of action worked out beforehand for the accomplishment of a goal. In the nursing process, planning involves determining beforehand the strategies or course of action to be taken before the implementation of nursing care. For effective planning of nursing care, the following are important: 182

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• The patient and family should be involved. • Plans should be patient oriented, individualised to patients’ needs. • Clear communication of the patient’s plan of care to all nurses involved should be provided. • It is important to establish a realistic nursing plan of care, avoiding setting goals that are too difficult or impossible to achieve. • Goals should be measurable. • Goals and expected outcomes (desired achievements) should be written in future tense. The planning of nursing care occurs in three phases, namely initial, ongoing and discharge planning. Each planning stage contributes to the co-ordination and development of the patient’s comprehensive plan of care.

Activities involved in planning nursing care During the planning stage, the nurse determines what can be done to help the patient meet his or her needs, and decides on nursing actions that will achieve this. This will include determining outcomes and nursing interventions, decisions on equipment, and methods to use in order to meet the identified needs. The planning stage also involves drawing up a care plan according to which the patient will be nursed (Figure 10.1). 1. Assessment 2. Diagnosis

Recording

Recording

Recording Recording

3. Planning • Setting priorities • Setting goals and developing expected outcomes • Selecting appropriate nursing interventions • Writing nursing care plans

5. Evaluation 4. Implementation

Figure 10.1  Activities in the planning phase of the nursing process

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Priority setting

Setting priorities is about choices and alternatives. It involves making decisions about the sequence in which the patient’s problems will be addressed. The principles used in determining nursing care priorities will depend on the patient care setting. • Maslow’s hierarchy of needs model. If this model is used, the life-threatening diagnosis should be given priority. This method of prioritising is useful if the patient is physically ill and not in a state to make decisions about his or her own care. In these circumstances, the use of Maslow’s hierarchy of needs model is appropriate, and the nurse applies his or her professional expertise to ensure that the most vital of the patient’s physiological life-threatening needs are met first. • Where the patient is able to make decisions, the nurse, in collaboration with the patient, can first meet those needs that the patient feels are most important. This method of prioritising is suited to the primary healthcare situation in which individuals and communities are encouraged to identify their own needs and problems, and work with healthcare professionals to meet their healthcare needs. • Nurses can consider potential future problems and deal with those that are most likely to develop. This method of prioritising is useful in situations in which active measures are required in order to prevent a problem from developing. If, for example, a relatively immobile patient with a fragile skin is at risk of developing pressure sores, specific nursing actions must be implemented in order to prevent this. This method of prioritising care is also useful for mentally ill patients. While such patients may be physically well, they may be at risk of self-destructive or aggressive behaviour, and nursing actions are necessary in order to prevent such incidents. Setting goals and developing expected outcomes

The goals of nursing care are the results or desired outcomes of nursing care. There are two categories of goals, namely short- and long-term goals. Short-term goals can be met quickly within hours or a few days, whereas long-term goals are achieved over a long period of time. Development of outcomes refers to formulating and documenting realistic patient-focused goals. Outcomes provide direction for the continuity of patient care in order that the nurses’ competencies are matched with needs of patients. Outcomes define a situation where a goal has been met, and nurses assist with evaluating the extent to which this has been achieved. Outcomes of care identify the results that the nurse expects to achieve by the nursing care of the patient – the changes that will be brought about by this care. For example, in a patient whose nursing diagnosis is altered sleep pattern related to pain as evidenced by wakefulness, restlessness and complaint of pain, the goal is pain relief and the expected outcomes will be the patient will have a restful sleep and within eight hours, and the patient will report that the pain is absent or diminished. Expected outcomes should be as follows: • They should be derived from actual or potential diagnoses to ensure that planned interventions based on the outcomes are appropriate and relevant. • They should be patient oriented in that they should describe what will be seen in the patient, and not what the nurse proposes to do with the patient.

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• They should be individualised, realistic and culturally appropriate, taking into account the age of the patient, present and potential capabilities, as well as the religion of the patient. • They should be mutually formulated with the patient, family and other healthcare providers where possible, and should be appropriate for the patient. In other words, the patient must be able to achieve the outcomes, and the outcomes must also allow for ongoing assessment of the patient’s progress and response to treatment. • They should be attainable within a defined period of time and in relation to available resources. An unattainable outcome is impractical and does not allow for a realistic evaluation of nursing care. • They should be measurable and time bound. In other words, they should provide a time estimate within which the expected outcome should be achieved. Determining time frames involves deciding how much time should elapse before the patient shows a response to treatment. Time frames vary according to the nature of the patient’s needs and problems, and may not be necessary for chronic and ongoing problems. In acute situations, time frames should be stated. For example, if the patient does not respond within the specified time period, medical assistance will have to be summoned, the patient’s treatment will have to be changed, or current nursing interventions will need to be reviewed and, where necessary, changed. • They should be specified for each nursing diagnosis. • They should be flexible and take other forms of treatment into account. The patient, as well as the doctor and other members of the healthcare team, should feel that the outcome is valid and worth attaining. Depending on whether the identified problem is an actual or potential one, the following verbs can be used to formulate expected outcomes: • To promote, maintain, restore and relieve (actual problems) • To prevent (potential problems). It is also important to describe the evaluation criteria. These will be used to monitor progress towards or to assess the effectiveness of the nursing intervention as evidenced by resolution of the problem. As in all the steps of the nursing process, outcomes should be documented. Selection of nursing interventions

Nursing interventions describe nursing activities which are directed at enabling patients to meet their needs and achieve the expected outcomes of care. The types of interventions are usually nurse initiated (for example elevating an oedematous limb), dependent (for example administration of the medicine prescribed by the doctor) and collaborative (for example consulting a dietician when teaching a patient about diet for his or her medical condition). When selecting and specifying nursing actions, the following aspects must be considered: • Nursing interventions should be individualised, based on the identified assessment findings and the expected outcomes of care. • The sequence in which nursing actions will be carried out should be according to the identified priorities of care. 185

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• Each intervention should be supported by a scientific rationale. • Nursing interventions should be legal and ethical – that is, they must be in line with the scope of nursing practice and not in violation of the patient’s rights. The intended interventions should thus be discussed with the patient and family wherever possible, and suggestions from the patient should be taken into account to ensure that both patient and family feel that the envisaged plan is worthwhile and valid. • Nursing activities must be safe, and must not cause harm to the patient in any way. Standard protocols and standing orders relevant to the patient should be specified. • Nursing actions must be compatible with other forms of treatment prescribed for the patient, and the nursing regimen must be able to accommodate the activities of the other members of the multidisciplinary healthcare team who are involved with the patient. • Nursing actions must be scientific, and nurses must use the correct procedures and techniques to resolve patients’ problems. • Nursing actions should be effective. In other words, the planned nursing actions must be selected and applied in order to achieve the expected outcomes. • Nursing actions should be practical in terms of the patient, the available equipment, and the staff and their experience. Drawing up a nursing care plan

Nursing care plans consist of orders regarding the nursing interventions to be carried out in order to achieve the expected outcomes. The characteristics of a good nursing care plan are as follows: • It must be individualised and tailored to meet the patient’s needs. • It must be based on the goals to be achieved. • It must be holistic, sequential and measurable. • It must be able to provide a scientific rationale for all nursing actions. • It must be flexible and cost effective. • It must be written out. The standardised care plan is a preplanned, preprinted guide for the nursing care of patient groups with common needs. This type of care plan generally follows the nursing process format. Standard care plans are useful as teaching tools. They also help to provide consistency of care, and can be used as a reference by staff members who are unfamiliar with the clinical area. Standard care plans are also useful in very busy clinical areas where such plans may be used to streamline administration and record keeping. Standard care plans should not, however, be applied without individual assessment of patients, and without adapting and tailoring the standard care plan in the light of such assessment. In other words, standard care plans must be individualised before being used on patients. A written care plan is a blueprint of actions aimed at facilitating easy and directed implementation and evaluation of the patient’s response to nursing interventions. Written nursing care plans give orders regarding the nursing interventions to be carried out. They also describe specific activities to be done by all nurses caring for the patients. Advantages of written care plans are as follows: 186

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• They state clearly the problems and goals, and these are used as the basis for decisions about the nursing care to be given. • They communicate priorities in nursing care. • They are available to all health workers who come into contact with the patient. • They ensure that the patient receives consistent nursing care. • They enhance continuity and co-ordination of care. • They make it possible to evaluate nursing care techniques and standards of care by determining whether the stated goals were achieved by means of planned nursing activities or not. • They identify and co-ordinate resources. • Through written care plans, information exchange is organised in change of shifts reports. • They are excellent teaching tools in the ward situation. A care plan should be drawn up for each patient and should contain the following: • The nursing diagnosis (from the assessment findings) • The expected outcomes for each nursing diagnosis • The planned nursing interventions. Table 10.3  Nursing care plan Nursing diagnosis

Goals/expected

Nursing interventions

outcomes

Acute pain related to myocardial ischaemia as evidenced by complaint of pain and restlessness

Within eight hours, the patient will report that the pain is absent or diminished The patient will have a restful sleep

• Assess pain characteristics (location, quality, severity, duration, onset, relief) before and after the administration of prescribed analgesics • Score the pain • At the first sign of pain, encourage the patient to relax • Administer prescribed sublingual nitroglycerin • Continue to monitor the pain every five minutes • Notify the doctor responsible for the patient if there is no pain relief after administration of three prescribed doses of nitroglycerin • Administer oxygen by mask as prescribed • Maintain bedrest • Provide a quiet environment • Offer emotional support • Explain all procedures performed • Encourage questions from the patient • Document all procedures done

Validating the care plan

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as possible. When validating a care plan, the following aspects should be taken into account and checked: • Patient safety should receive priority. • The plan should be based on scientific principles. • The plan should be developed in collaboration with health team members, the patient and the family, and in a manner that each member’s contribution towards attaining the outcomes is encouraged. • The nursing diagnoses should be supported by the assessment information, and not based on assumptions. • The expected outcomes should be designed to alleviate identified needs and problems. • The expected outcomes should be measurable, and it should be possible to use the expected outcomes to evaluate a patient’s progress. • It should be possible to achieve the expected outcomes by means of the planned nursing actions. In other words, planned nursing actions should be effective. • The nursing actions should be arranged in a logical sequence and reflect identified priorities of care. • The plan should be individualised for each patient and it should take the patient’s likes and dislikes into account as far as possible, meaning that it should reflect the patient’s characteristics and needs. • The nursing care plan provides for continuity of patient care. • As far as possible, the plan should take the patient’s own priorities into consideration. • The plan should ensure that relevant records are kept in line with the hospital protocols. Once validated, the care plan is put into operation. The nurse continues to observe, assess and collect information during the implementation of the care plan.

Implementation of a care plan This step involves putting the designed plan into action. Care plans should be checked and validated before they are implemented, and they should be written down and made available to all staff in order to ensure continuity of care. A patient’s care plan should also be used as the framework for recording nursing care and patient progress. In other words, the elements of a patient’s care plan should form the basis of daily reports, cardex or routine nursing records relating to patients. During the implementation stage, the nurse should continue to reassess the patient. The following guidelines should be followed when implementing interventions: • Base nursing interventions on scientific knowledge, nursing research and professional standards. • Do not implement any order that you do not understand – ask questions and request guidance. • Give safe and holistic care. • Respect the patient’s right to dignity, confidentiality and autonomy to enhance self-esteem. • Adapt activities to the patient’s values and beliefs, age and environmental factors. • Provide support, information and comfort to enhance achievement of goals. • Involve the patient actively during implementation of a care plan. 188

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Evaluation of a care plan Evaluation involves assessing a patient’s response to nursing interventions. To evaluate the care plan, the achievement of the expected outcomes is assessed using the specified evaluation criteria. Evaluation of the care plan is a systematic, criterion-based and ongoing process, and not something that occurs just prior to the discharge of a patient. The care plan may have to be revised according to the results of the evaluation. The measurement criteria for evaluation are as follows: • The patient, family and the multidisciplinary team are involved in evaluation. • Evaluation takes into account the set time frames after interventions are started. • The effectiveness of the interventions is based on the achievement of the set outcomes. • Ongoing evaluation results in revisions of nursing diagnoses, outcomes and plan of care. • The evaluation date is documented in accordance with principles of record keeping. The four possible outcomes of evaluation of the nursing care plan include the following: 1. Goal completely achieved. 2. Goal partially achieved. 3. Goal not met. 4. New problems or nursing diagnoses have developed. Revision of the care plan

The care plan should be revised if the expected outcomes are not achieved or are only partially achieved: • The priorities of care may have changed, requiring an alteration in the plan or in the sequence of the interventions. • Priorities may change as a result of a reaction to treatment or as a result of complications that could be due to treatment or to an exacerbation of a patient’s medical condition. • It sometimes happens that a new problem arises which is unrelated to the needs and problems identified at the time of the initial assessment of a patient. A patient may present with a myocardial infarction while undergoing routine surgery for a minor problem. The unexpected can never be disregarded in patient care, and nurses should be on the alert for it. Careful assessment and identification of underlying chronic problems may, however, reveal possible unpleasant surprises. • While revising the care plan, nurses should examine the planned nursing care very closely. In particular, nurses should assess the care plan for unrealistic outcomes, inaccurate nursing diagnoses and ineffective nursing actions.

Note: Record keeping Record keeping is an essential requirement for the effective use of the nursing process and the implementation of care plans. Nurses should bear in mind that in the majority of Nursing Council disciplinary hearings, the accused’s case stands or falls on the grounds of patient records. • Recording must take place at every stage of the nursing process. ➙

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• Nursing records are legal documents and must reflect accurately and honestly the nursing actions carried out for a particular patient. • Records are an important way in which the accountability of nurses is reflected – records provide proof that nursing care was carried out. • Nursing records must be concise and correct, and must reflect the true facts regarding the patient. • All statements made on a patient’s nursing record must be indelible and must show the time and the date that they were made, and be signed by the person making them. All nursing and medical activities, treatments, investigations, and the patient’s response to treatment and nursing care must be recorded in ink. The nurse should record everything that happens regarding the patient. Patient records must be complete, and it should be possible to gain an accurate history of the patient’s progress from the records long after the patient has been discharged.

Conclusion The nursing process is a methodical step-by-step approach to patient care, which is flexible and can be adapted and used in every clinical situation. The use of the guiding principles of assessment, planning, implementation and evaluation ensure that nursing care is holistic and individualised for each patient. The use of logical methods in nursing enhances professionalism and quality of care by making patient care and its recording more precise and accurate. The use of the process also encourages creative and independent thinking in nursing. Nursing care becomes a specific process that is unique to nursing. The nursing process eliminates the unthinking application of routine patterns of nursing care that have been learnt by rote. Nursing care becomes a dynamic and interpersonal interaction between nurse, patient, family and community, with many positive results. The third step of the nursing process is planning. This step involves determining beforehand the course of action to be taken before the implementation of nursing care. For effective planning of nursing care, the patient and family should be involved, and nursing care plans should be patient oriented and individualised to meet the patient’s needs. Nursing care plans should be validated before, during and after implementation.

Suggested activities for students Answer the following questions to test your knowledge and comprehension of this chapter.

Activity 10.1 Select the most appropriate answer/s from the following questions by encircling the letter that corresponds to the correct answer (eg 1:f) 1. The plan of nursing care includes the following: a. Client assessment data, medical treatment regime and rationales, and diagnostic test results and their significance ➙

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b. Doctor’s orders, demographic data, and medication administration and rationales c. Collected documentation of all team members providing care for the patient d. The patient’s nursing diagnoses, goals and expected outcome objectives, and nursing interventions

2.  When establishing priorities of a patient’s plan of nursing care, the nurse should rank the highest priorities to life-threatening diagnoses and the lowest priorities to: a. Safety-related needs b. The patient’s social, love and belonging needs c. The needs of family members and friends who are involved in plan of care d. The needs of the patient regarding referral agencies 3. What is the main purpose of the expected outcome? a. To describe the plans to be taught to the patient b. To describe the behaviour the patient is expected to achieve as a result of nursing interventions c. To provide a standard for evaluating the quality of healthcare delivered to the patient during the hospital stay d. To make sure that the patient’s treatment does not extend beyond the time allowed under the diagnosis-related group system 4.  What are the essential components of an expected outcome? a. Nursing diagnosis, interventions and expected patient behaviour b. Target date, nursing action, measurement criteria and desired patient behaviour c. Nursing action, patient behaviour, target date and time d. Target date, nursing action, measurement criteria and rationale 5. After assessing the patient, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first: a. Altered nutrition b. Anticipated grieving c. Ineffective airway clearance d. Ineffective tissue perfusion

Activity 10.2 Write a nursing care plan for a patient admitted in a medical ward complaining of a headache. The patient’s blood pressure is 180/110 and she tells you she has never heard of hypertension.

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11

Home- and community-based care

Learning objectives On completion of this chapter, the student should be able to do the following: • Define the term ‘home- and community-based care’. • State the essential elements of home- and community-based care. • Identify the goals of home- and community-based care. • Explain the advantages of home- and community-based care. • Describe the purpose of a discharge plan for patients referred from traditional healthcare centres to home- and community-based care. • Describe the process of discharge planning for patients referred from a hospital to home- and community-based care. • Explain the roles of team members involved in home- and community-based care. • Use the steps of the nursing process to provide home- and community-based care for a patient referred for community and/or home care from a traditional healthcare institution.

Key concepts and terminology Ecomap: Environmental layout that includes the community. Genogram: Structure of the family with a view to ascertaining the position of the patient within the family as well as determining who is best in the family to assume the role of the principal caregiver. Home- and community-based care (HCBC): Alternative care to the traditional healthcare of clinics and hospitals, which is provided at home or in the community by family or community members supported by professional health workers. Palliative care: Specialised care that improves the quality of life of patients and their families facing the problems associated with life-threatening illness through the prevention and relief of suffering by means of early identification, assessment and treatment of pain and other physical, psychosocial and spiritual problems.

Prerequisite knowledge The nurse should have knowledge of the following: • Basic nursing care • Community/family healthcare.

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Medico-legal considerations The discharging nurse is responsible for ensuring an environment at home which is conducive to the care of the patient. He or she has a responsibility to: • emotionally prepare the family for the arrival of the patient • teach the family about safe provision of care to the patient • ensure that all patients are entitled to access safe and culturally relevant home- and community-based care, regardless of their race, age, gender and sexual orientation.

Key ethical considerations Ethical considerations in home- and community-based care include the following: • A thorough assessment of the patient before discharge from the hospital, clinic, hospice or general practice to the home so as to establish physical and emotional preparedness for self-care • An assessment of the patient and his or her family’s ability to provide care at home • Protection of the patient’s rights with regard to privacy, confidentiality and preferences of the caregiver • A moral obligation to refer to the home- and community-based team and to follow up on the patient in the community • A moral obligation to educate the patient and the family about the illness and its management.

Essential health literacy Health education aspects communicated to the family should link to home- and community-based care. It is important to reduce dependency on formal health institutions and let families take responsibility for care. Campaigns on basic principles of personal and environmental hygiene should be held periodically to assist communities and family members to look after their own. Issues related to self-medication and over-the-counter medicines must be included in the education because in many instances the use of these may pose a challenge when used at home. This should include the types of medicine that can be kept at home, their dosage, frequency and storage.

Introduction The increase in non-communicable and chronic diseases such as cancer, diabetes, hypertension and the complications involved, the ageing population with its related illnesses and the unrelenting HIV infection and AIDS worldwide have prompted the healthcare delivery system to review the current tradition of relying only on formal healthcare provision such as healthcare centres, clinics and hospitalisation of patients. As more people become ill, the current health institutions are no longer able to cater for patients’ admission needs. Home- and community-based care is viewed as an 193

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alternative care model that can offer sustainable and cost-effective care across the continuum. This has become a national policy priority aimed at minimising the impact of disease on the formal health sector, and relieving hospitals and formal healthcare services of the burden of carrying the sole responsibility of patient care. Home-based and community-based care are interrelated, and one occurs within the context of the other. The purpose of this chapter is to provide knowledge and skills to enable nurses to care for patients and their families in the home setting.

Home- and community-based care defined The WHO has defined home-based care as the provision of health services and care by formal and informal caregivers in the home in order to promote, restore and maintain a person’s maximum level of comfort, function and health, including a dignified death. According to this definition, home-based care is an integral part of community-based care. Home- and community-based care can also be explained as a comprehensive service that includes healthcare and social services by primary and community caregivers in the home of the sick person. The primary caregiver may be the parents, spouse, children, relatives and/or significant others. This type of care is proposed where the patient is to leave the traditional institutional care but still needs assistance, whether partial or otherwise, to meet self-care requirements, especially in relation to activities for daily living. This requires a discharge plan to be outlined before the patient can be released from the hospital so that continuity of care is assured. Home- and community-based care should be comprehensive (health promotion, preventive, curative, palliative and rehabilitative) and holistic (physical, psychosocial and spiritual), involving the provision of a network of resources and services offered throughout the continuum of care. The care should include the following: • Medical and nursing care • Training and support of the caregiver • Counselling and social support • Spiritual and pastoral support • Material, financial and practical support and referrals.

Essential elements of home- and community-based care The essential elements are as follows: • The environment, which includes the home and the community • A multidisciplinary care team • Support networks, some of whom may visit the patient regularly • A supervisor and liaison person, who could be a registered nurse or doctor, and may form part of the team • A local clinic/health institution to provide basic medicines, supplies and laboratory facilities • A community hospital or hospice as back-up for patients requiring admission • A good referral system within the primary healthcare service. Home- and community-based care and support ensure the provision of a continuum of care and normalisation of services for persons who have become vulnerable to 194

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chronic conditions such as HIV infection and AIDS. It ensures that people have access to integrated services that address their basic needs for food, shelter, education, healthcare, family or alternative care, and protection from abuse within the confines of their homes or communities.

Goals of home- and community-based care The goals of home- and community-based care are to: • maintain, restore or promote the physical, mental, social and emotional wellbeing of individuals who are recovering from or are faced with a long-term illness • enable families and communities to effectively render prevention, early intervention, care and support to those patients with chronic illnesses • address the needs of the most vulnerable people, such as older persons, children, youth and people with disabilities • support and facilitate the delivery of services and to build capacity in communities, especially the non-governmental organisations (NGOs) • address immediate needs and issues facing communities, such as poverty, as they relate to basic needs and resources, and to promote sustainable development • establish a well-functioning referral system to hospitals, hospices, clinics and other healthcare facilities in the community, thereby giving communities access to services nearest to or at home.

Advantages of home- and community-based care Home- and community-based care is given by people within the community and as such encourages participation by people, responds to the needs of people, encourages traditional community life and strengthens mutual aid and opportunities and social responsibility. This care might be given by nurses, midwives, trained volunteers, community health personnel, interest groups like traditional healers, community leaders, other groups from both government and NGOs, and community-based organisations (CBOs). Home- and community-based care means providing the right level of intervention and support within the community setting to enable people to achieve maximum independence and control over their own lives. The care can be provided in a home, hospice and day-care facility such as a clinic or community centre. It can mean being at home with the family who cares for the patient with help from outside, or care given by health professionals and/or volunteers with inputs from friends and family. In a day-care facility, the patient is usually removed from the immediate home environment and looked after by people other than the family during the day while the family is relieved to participate in activities for daily living, including their employment. Care in such facilities includes physical personal care, administration of medication, palliative care, emotional support and counselling, rehabilitation, occupational therapy and physiotherapy. A hospice offers a form of care that focuses on the relief of the patient’s physical and emotional pain and suffering more than treating the underlying disease. The facility is usually managed by the community, which makes very little, if any, profit. 195

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Advantages of home- and community-based care • All communities are capable of offering services, support and care to families, provided they are strengthened and supported. • A family home environment is the most appropriate place for the care and support of people with chronic illnesses as opposed to institutional care. • Removing people with chronic conditions such as HIV and AIDS from their homes and communities at any stage can only promote denial, stigma and discrimination. Caring for people in their homes and communities makes HIV and AIDS a socially acceptable community issue rather than just a health problem. • If both family and community resources can be mobilised, conditions such as HIV and AIDS could be better managed in the home. • Caring for people in their homes and communities makes illness a social as well as a community health issue rather than just physical individual debility. The approach does not mean shifting the burden of care by government to families and communities, but the intention is to ensure that patients have access to integrated services that comprehensively address their basic needs and that the community’s capability for self-determination is enhanced. • It is cheaper to provide home- and community-based care because the cost of hospitalisation and transportation to and from the hospital may have huge financial implications for the family.

Up to 70–90% of care during illness takes place within the home. Research evidence indicates that people would prefer to be cared for in their home environment and that effective home care improves quality of life for ill people and their primary caregivers. Throughout the world, most caregivers are family members (usually women and young girls).

Discharge plan A discharge plan is a written outline of the care to be given after the patient is discharged from a traditional health centre like a clinic, hospital or hospice. The plan can include a follow-up care plan for a client who is to receive aftercare from a health or community care centre. The plan is usually written by the discharging institution to the one taking over the care involved. Discharge planning is a process designed to make the necessary arrangements for patients and their relatives to continue with health and social care at home by themselves, a family member or the community through community health workers, volunteers and other interest groups. The purpose of a discharge plan is to: • provide continuity of care • provide a cost-effective service • ensure the follow-up of patients • ensure quality care based on a good referral system.

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Guiding principles related to discharge planning are as follows: • Participation – household members are included in the plan. • Volunteerism – stakeholders are involved, at an individual or group level, in the activities of the programme of their own volition. • Non-partisanship – the primary concern is the wellbeing of the client, irrespective of political, religious or any other form of affiliation. • Empowerment – families and communities are capacitated and strengthened to be able to take over their own care. • Partnership – the home- and community-based care programme does not suggest a shift of responsibility for care to the client or patient. It is a shared responsibility between government and community. • Holistic – basic services offered to the target group assume an integrated approach, therefore home- and community-based care is not exclusive to a particular group of patients, for example those with HIV/AIDS, but it is designed to offer services to all vulnerable groups. • Developmental – basic services offered seek to empower patients and thus avoid treating them as dependent victims but rather as capable individuals, groups and communities who can confront such adversities on their own in the future.

Process of discharge planning The programme for home- and community-based care needs to be integrated into the local health facility. For the discharge plan to be appropriate, it should follow a process that is based on community assessment and the nursing process. It is important for a nurse to know the patient’s physical residence, as well as the degree of the illness from which the patient is recovering. The physical environment will provide knowledge on the availability of facilities and resources, both human and material. Of importance are the expectations of the patient and those of the family, as these are to be considered in the plan. The process should include the following: • Essential elements of home- and community-based care • Development of strategies to attend to the physical needs of ill people • Development of strategies to attend to the spiritual and emotional needs of ill people, caregivers and other members of the team • Development of strategies to promote effective palliative care • Development of strategies for effective orphan care • Determination of supplies and equipment required to provide care, which could include the essential drug list for home- and community-based care and HCBC kits • Determination of the ordering system for supplies to ensure a continuous supply of equipment and supplies, and development of a system to manage supplies, equipment and HCBC kits • Ensuring that there is space available for storage • Ensuring that there are supervisors for home- and community-based care programmes. Components of the discharge planning process include the following: • Assessment of the patient’s, the family’s and the community’s needs 197

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• • • •

Analysis of these needs Making a diagnosis and setting out a plan Implementation of the plan Evaluation of outcomes.

Assessment

This involves data collection to identify the possible immediate and subsequent needs of the patient while discharged from the traditional health facility. The needs identified in this session should be validated and verified by means of a follow-up assessment during a visit to the home of the patient. Assessment of the family involves the use of the five senses (hearing, touching, seeing, tasting and smelling) in order to identify actual, potential and possible problems that may compromise care in the environment. Genogram

One example of an assessment tool to be used is the genogram. The genogram is used to gain a perception of the family structure so that the patient is properly placed within the family. A family tree structure is drawn up by interviewing the patient and family members in order to identify the appropriate person in the family to act as the primary caregiver. Ecomap

An ecomap may be used to provide additional information regarding a family as a system and its interaction with other systems in the society, such as church, industry, healthcare, etc. This becomes important in cases where the immediate family may not be available to act as primary caregivers. In such cases, the ecomap provides information on neighbours, church members or friends who can participate in the caring of the patient with permission from the patient and his or her family. Biographic information

Information to be collected about the patient includes name, address, contact number if available, age, gender, marital status, occupation, employment status, diagnosis and next-of-kin or person to be contacted in an emergency. In rural communities, it is important to obtain information about the location of the home of the patient in terms of the village, the local leader/chief, and landmarks such as a school or a shop that will assist to locate the home of the patient. Analysis of needs and diagnosis

The identified needs are itemised and prioritised in terms of the patient’s ability to perform activities for daily living such as bathing, dressing, elimination and feeding, as well as supporting functions such as housekeeping, taking medication, transportation and finance management. Planning

A plan to meet the identified needs in their priority should be set. Available resources and those to be generated should be outlined. The plan should indicate who is to do what, why, where, when and how. 198

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Before referral to home-based care, it is important to determine the following: • The implications of the diagnosis and treatment for the family and how the illness has or will affect family life • Whether the patient can care for him- or herself and, if not, who will, according to the genogram or ecomap, provide this care (primary caregiver). • The financial status of the patient and that of the family, including the availability of health insurance. Most of the patients may be unemployed and thus not have health insurance. In that case, the nurse should find out about the possibility of applying for a disability or old age grant if the patient does not have one already.

Implementation of the plan The following aspects need to be taken into account during implementation of the plan: Basic physical care

Physical care at home involves providing basic nursing care and comfort measures. Such care includes recognising symptoms, making nursing diagnoses, giving treatment, managing symptoms, making referrals and following up. In addition, issues related to prevention and protecting the ill person and caregiver through the use of standard precautions are included. It is important to identify the basic needs of shelter, food and clothing, as well as other resources necessary for comprehensive care. • Basic nursing care includes positioning, mobility, bathing, wound cleaning, skin care, oral hygiene, adequate ventilation, and guidance and support for adequate nutrition. • Symptom management depends on the ill person’s condition. However, basic symptom management includes reducing fever; relieving pain; treating diarrhoea, vomiting and cough; and providing skin and mouth care. Maximum rest and comfort are provided for, while counselling is offered for psychosocial and emotional problems that often accompany chronic illness. The HCBC team should have basic home-care kits supplied by the NGO or clinic. These usually contain prescribed medicines and supplies for home care. Standard precautions

The use of standard precautions should follow national guidelines. These include hand washing, laundering linen with soap and water, using appropriate disinfectant and detergents, and burning or safely disposing of rubbish. These precautions should be taken regardless of the patient’s condition. Protective devices such as gloves, goggles and overalls should be used whenever necessary, especially if in contact with blood or body fluids. Palliative care

Palliative care is a combination of active and compassionate long-term therapies intended to provide comfort and support to individuals and families living with a life-threatening illness. Such care strives to meet the physical, social and spiritual needs of ill people and their caregivers. This requires a team approach including the patient, the family, health and social workers as well as community care workers or

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volunteers. Terminal care aims at improving the quality of daily living at the end of life by relieving the symptoms, especially pain, and enabling the person to die peacefully, with dignity and in keeping with his or her wishes, which may also include assisting the person to draw up a will and a succession plan. Pain relief

Pain relief is an essential element of palliative care, and care workers need to be educated about how to effectively manage pain. Aspirin and paracetamol are usually available for pain relief, but are often not given in adequate doses or in good time to relieve pain. It is important for trained health workers to familiarise themselves with national policies and guidelines in the management of pain so that they can administer other scheduled drugs in the management of pain according to protocols. Spiritual and emotional support

Caring for a person in the terminal stage of an illness is strenuous for the family, children, community, health and social workers, and other providers. The process of bereavement commences well in advance before death for the family. It is therefore important that during the family member’s illness, support is enlisted from the community including ministers of religion, neighbours and friends. Families need help in discussing death and making plans for the future. Such plans may include making a will, funeral arrangements, where to place orphans, and memory projects for surviving children. Dying without a will denies children and other family members, especially women, of their right to inheritance. It is thus important to help the family to prepare for death. Bereavement counselling

Providing support and counselling is very important for the family and members of the HCBC team. Counselling should be continued as long as possible. Bereavement issues, especially those of orphaned children, should be attended to. The basic elements of effective communication can be used to address issues related to dying for both individual and group bereavement counselling. Patient education

It is important to teach patients about their own health problem prior to discharge. Health teaching for the patient and family is an integral part of discharge planning. Nurses should make sure that all teaching done is recorded in terms of the ability of the patient and/or the family to perform the tasks. The patient should be taught the names of medications, and their purpose and side effects, as well as related activities, such as wound care, catheter care and the administering of injections, that are to be continued in the home. Referral

A referral is a written communication between the hospital and the HCBC team, or vice versa. Referrals provide co-ordination and collaboration between the different care settings. Referrals to home care should include care provided at the referring institution, activities that the patient and family are expected to perform at home following home

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assessment, and the patient’s and family’s ability to do these. The referral must clearly indicate where the patient and relatives are to go for assistance should this be necessary. It is important to formulate a working relationship between hospital, clinic and HCBC team to evaluate the process. This feedback will assist the healthcare system to improve on the quality of a discharge plan and the process involved. A meaningful referral form should contain the following information about a patient: • Current health status • Current and subsequent healthcare needed • Projected level of care needed • Care, teaching and therapies that should be accomplished • Ability and willingness of the patient/family/significant others to participate in care giving • Financial resources of the patient • Available community resources. Home assessment

Information about the home environment is necessary before the patient can be discharged. A home visit must be done by a nurse, social worker or community health worker in order to introduce the team and do an assessment to determine how easy or difficult the task of home care will be, based on resources available. These will include availability of running water and energy sources, such as electricity; size, structure and status of the house and the home environment; sanitation, indoor water-borne toilet, commode; living arrangements; and ability to use assistive devices like a wheelchair in and around the house.

Responsibilities of the referring facility The referring institution has the responsibility to: • discuss with the patient and the family or the significant others the proposed homeand community-based care as an alternative model of care, and obtain their consent/agreement and acceptability based on an informed decision • assess the patient’s readiness for referral/discharge • inform the home-care provider to which the patient is referred to allow for notification and preparation to receive the patient • provide instructions on the use of applicable medications, purpose for use, dosage and storage • where possible, observe the understanding of the caregiver and/or patient on the usage of medication and appliances • inform the caregiver and the patient on follow-up care requirements and appointments • advise on any specific care, for example nutrition, hygiene, oral care, pain control, infection control, mobility, wound care, etc • provide devices or related advice on aspects such as pharmaceutical supplies and dietary supplements ➙

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• provide social assistance forms and sick leave certificates, and assist in their completion and submission to the relevant authorities • send a referral form to the primary care site that will take over the care of the patient • arrange transport for the patient to go home • inform the patient/family/significant others of the formal/informal partnerships and the relevant lines of communication.

The team involved in home- and community-based care Home- and community-based care is a collaborative effort. The team includes the patient, the primary caregiver (family member), healthcare workers (nurse, counsellor, social worker, doctor, community health workers, traditional healers and volunteers), and social services providers. These are supported by an efficient referral system within the primary healthcare setting. The more involved the community is, the more cost effective, comprehensive and holistic is the care.

The role of the primary caregiver The primary caregiver is a key member of the team. He or she can be a family member, spouse, neighbour or friend. This person should preferably be someone living with the patient in the same house, and will be the co-ordinator of care. Prior to the discharge of the patient to the home, the nurse should establish through a genogram or ecomap who the appropriate individual will be to serve the role of primary caregiver. This individual must be counselled and trained in preparation for the task ahead. He or she should be offered ongoing support from the home-care team. In poor communities, the grandmother plays a very important role, especially as AIDS affects young mothers and wives. The role of the nurse Historically, nurses, women and female children have been responsible for provision of care in the home. A nurse’s role is that of a case manager giving direct care to the patient, information and guidance to the relatives. Nurses should be responsible for doing the first visit to the patient’s home to make the initial assessment before a discharge plan is drawn. The nurse must also obtain information about the community in relation to resources available specific to the care and support of this patient. In cases where there are trained community health workers, the nurse can entrust that responsibility to them, but the ultimate accountability remains with the nurse, whose role includes the following: • Patient and family assessment • Nursing care • Medical treatment • Education • Assistance with basic needs (food, shelter, supplies) • Social support • Referral for financial support • Emotional support 202

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• • • • •

Spiritual care Counselling Referral for services beyond his or her capabilities Practical support for the caregiver Bereavement support.

The role of the doctor The doctor and/or the clinic nurse both have the responsibility to communicate the necessary information about the patient to other members of the healthcare team, which is done through a referral form. The doctor/nurse team must also be available should their services be needed in the home. The role of the social worker The social worker is an important member of the HCBC healthcare team. The office of the social worker helps patients with their social and emotional problems, such as applications for and the processing of pension fund and disability grants, as well as grants for orphans. Social workers also provide assistance when there is a need for counselling and crisis intervention. The role of the nutritionist In many areas in South Africa, nurses perform the function of a nutritionist. Nutrition counselling is important in home care, especially given the nature of debilitating illnesses with which the healthcare services are faced, such as AIDS, cancer, diabetes, hypertension, etc. The caregiver needs to be given advice on the diet of the patient. In poor community settings where families are destitute, the healthcare services might have to assist the family with food parcels through the office of the social worker. This might be the only source of food complement for the family. The role of community health workers/volunteers Many community health programmes run by NGOs offer home-based care. These organisations use the services of trained community health workers who are often the first contact with the patient in the community or home. This category of health workers plays an important role in home healthcare in South Africa. They receive training in home healthcare from a nurse or doctor, which covers aspects of basic nursing care, wound care, medication and hygiene, and in some cases symptom control such as pain, diarrhoea, skin care, and care of bed sores. They also receive training in standard precautions for the prevention of infection. The role of support groups Volunteers in the neighbourhood of the patient may form support groups. Some support groups are formed by people suffering from a particular ailment (eg HIV and AIDS, diabetes, cancer) in order to give each other support and share their experiences of what does or does not work. Other members of the team of health workers include physiotherapists, occupational therapists, and traditional and spiritual healers.

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Provision of home- and community-based care Planning for home care should start at the time of diagnosis of the illness. Care given should include clinical management, direct patient care, education, prevention, counselling and palliative care, and grief, bereavement and social support. Adequate support should be available from the clinics as well as the hospital, with a complete supportive team within the primary healthcare system. In that case, expensive inpatient care can be kept to a minimum with accessible and acceptable links and referral mechanisms in a comprehensive, holistic care continuum.

Procedures followed during home care It is important for home-based teams to collect data from patients about their personal needs, lifestyle and activities for daily living while they are still in hospital. A complete physical, psychological and social assessment of the patient should be done to evaluate the effects of the disease process on the patient and determine the direction to follow for care. The information obtained will serve as a baseline data for reference in the future. Physical assessment

This should include screening for the effects and evidence of diseases, such as dehydration due to diarrhoea, hypertension for blood pressure, abdominal distension for constipation, and discomfort for incontinence. Assessing for taste, smell, touch, pain and discomfort, and the condition of the skin, hair, nails, feet and teeth should all form part of physical assessment. Psychological assessment

This should include affective and cognitive status, level of esteem, level of mental stimulation, self-actualisation, beliefs, coping mechanisms, insight into the health problem, adjustment to the new role, and preparation for chronic illness and death. The presence of stress, depression, anxiety, loneliness/isolation, self-absorption, interest, motivation and value of health needs to be evaluated. Social assessment

This should include the willingness of the patient to be integrated into society, even with the incapacitation experienced and consent for home care. The patient should be made aware of the facilities in the community that are available and accessible to him or her. The assessment should include the patient’s lifestyle that can still be preserved or changed and the adjustment to the change. Following the hospital interview with the patient, the home-care team should plan a home visit to meet with the relatives of the patient, including the primary caregiver, before the patient is sent home. The purpose of the visit will be to: • introduce the team to the family and build a relationship with them • evaluate the views of the family about the patient, his or her illness and the prospect of home care • do a home assessment. A request for permission to visit the patient’s family must be presented. In the request it must be categorically stated who will be present at the visit so that the patient and 204

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relatives can give informed consent. During this visit, it is important to discuss with the family the knowledge they have about the patient’s illness, ensuring confidentiality where the patient has requested this (should the patient not want the family to know about the diagnosis, the nurse/health worker should not disclose this information but should continue counselling the patient until he or she is ready to do so), the preparations made for the discharge of the patient, the day and time of homecoming, arrangements made to receive the patient, and mode of transport to bring the patient home. When the patient has come home: • allow family members to be with the patient alone to discuss the illness and conduct the home-coming rituals • reassure the patient about confidentiality where necessary • intervene appropriately, depending on the health problem, for example giving pain medication, massage, exercise, education and hygiene when needed and necessary.

Basic nursing care Basic nursing care includes teaching the patient and the family about standard precautions of infection control irrespective of the patient’s diagnosis, such as the use of protective clothing, daily bed baths and wearing of clean clothes in a clean and wellventilated environment. Use of air fresheners and herbal mixtures, where available, might be useful to reduce or keep smells out. Other treatments such as dressing wounds, changing drains and tubes, giving medication, carrying out procedures for symptom control such as massage and keeping the patient clean, dry and comfortable should be taught to the family. Nutrition and hydration

A patient with a chronic disease should eat adequately to maintain tissue integrity and build immunity against microbes. HIV/AIDS patients specifically have special dietary needs because of related symptoms such as mouth sores, thrush and persistent diarrhoea. Nourishment should be light and given at frequent intervals. Dehydration should be prevented by the intake of fluids such as water, unsweetened fruit juices, soup, rice water and weak tea. Elimination and hygiene

Elimination may pose a big burden for people who are not nurses and those living in areas where there is no running water. Where possible, the task of clearing and cleaning the patient’s excreta must be made as easy and hygienic as possible. Caregivers must be provided with disposable gloves, pads and napkins. They must be taught how such supplies are used – that is, the application, hand washing and disposal of used material. Diet, fluid intake and exercise are again vital to regulate the system. Mental health

Chronic illness is depressing to the patient, as there may be structural changes and mobility restrictions that obviously impact on the person’s personality. In chronic illness, some people lose weight while others lose their capacity to think independently,

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are unaware of their environment, or become forgetful and confused. These changes may be upsetting even for the caregiver. To address these, the patient may need: • constant attention, reassurance and sometimes restraint • constant review of medication • removal of dangerous objects from the patient’s reach • sedation if the patient is confused. Caregivers may need: • information about the pathophysiology of the disease, the pharmacodynamics and pharmacokinetics of medications in order to understand the behaviour of the patient • encouragement in their rendering of care, as well as the necessity of taking turns to rest. Skin problems

Pruritis and itching caused by dryness may be problematic in an elderly patient. AIDS patients may have skin lesions such as sores and sarcoma. The family needs to be taught how to take standard precautions to prevent cross-infection in all patients, irrespective of the diagnosis. It is important for the caregiver to keep the skin clean and dry at all times by giving the patient a daily bath.

Standard precautions • It is important to teach the patient, as well as family members, about the importance of taking standard precautions to prevent cross-infection when dealing with all patients, irrespective of the diagnosis. • All members of the family and health workers should use barriers to prevent skin and mucous membrane exposure when in contact with blood, body fluids and excreta from patients, irrespective of the diagnosis. By doing this, the stigma attached to only certain types of diagnosis will be removed. • Gloves should be worn at all times when bathing the patient, dressing wounds, changing the napkin, and dealing with excreta or with open lesions and sores. A washable over-garment must be used to protect the carer’s clothes, and it must be washed at least daily. • Hands and other skin surfaces should be washed immediately if contaminated with blood or other body fluids, and regularly in between chores. • Hands should be washed after gloves are removed, and the gloves should not be reused. • All health workers and caregivers should take precautions to prevent injuries caused by needles or other sharp instruments. • Health workers and caregivers with skin lesions should avoid direct care of patients. Note: Bearing the above points in mind, the families of those infected with HIV or AIDS should be informed that they may touch such patients without fear of infection, and that they do not have to provide special eating utensils for them.

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Fevers and pain

Pain medication should be given according to the needs of the patient and not as per the nurse’s assessment. Pain relief is important in many patients with cancer and AIDS. The nurse should avoid worrying about the patient becoming dependent on the drug, but rather ensure that he or she is free from pain at all times to promote comfort.

Caring for the caregiver Family members, significant others and health workers all need to be supported and cared for, as the care they provide is very demanding. Support groups, individual and group counselling, provision of adequate resources, medical supplies and medications, as well as regular respite periods, are all strategies that can be employed in supporting the caregivers. Debriefing sessions are also very important for the emotional refuelling of all the caregivers.

Terminal care Patients who are dying need special care, as do their families. The following are elements that are important in caring for terminally ill patients:

Technology in home care Whether the setting is a hospital-based outpatient department or home, the need for technology is the same. Knowledge of the types and operation of supportive equipment and materials available specific to the patient’s situation is critical. This could include technology in relation to information, mobility and self-administered laboratory tests. Nurses should assist patients in the use of equipment that promotes independent functioning where possible and available. Hospice care A hospice is a home-like facility that provides care for patients suffering from lifethreatening conditions. In this environment, the patient is allowed to die in the comfort of a home-like setting surrounded by friends and relatives. The goal of most hospices is to keep patients at home for as long as is possible and only admit them if the family cannot cope. The aim is to keep the terminally ill patient free of pain and symptoms. The emphasis of hospice care is palliative rather than restorative care. Respite care In the course of a long illness, it is important for the family to get rest periods. This can be offered by admitting the patient either into a hospice or into other volunteer families’ homes for a few days. Respite may also be necessary for the community health workers working with terminal patients because of the demanding nature of the care involved.

Conclusion Home- and community-based care is a model of care that empowers families and communities to achieve maximum independence and control over their own lives and health. It provides both holistic and comprehensive care. Patients are cared for in 207

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the home environment by people other than the family during the day – that is, the caregivers – thus giving family members a break and allowing them to attend other engagements or go to work.

Suggested activities for students Activity 11.1 Case study Mr Nteo was admitted to the hospital with a cerebrovascular injury, which left him with hemiplegia and hypertension. He is referred for home care by the hospice staff a day before discharge. He lives with his wife, who is a pensioner. He also receives a pension, and has medical insurance with limited benefits. The nearest clinic is 15 km from his home, and he does have a telephone at home. He is on medication for hypertension. The discharge planner has prescribed nursing care in the home, physiotherapy twice a week and a special diet. • Formulate a preliminary care plan for your first visit with your patient the next day. • List the support services needed and referrals to be made.

Activity 11.2 Case study A community health worker receives a call from a woman who identifies herself as the landlady to Thomas, a 37-year-old man who lives alone in a room in her backyard. Thomas’s girlfriend was also living there, but she disappeared when he became ill. The man was discharged from hospital a week previously, and is unable to walk or cook for himself. His landlady has been giving him food daily but is not able to feed him or provide other means of care like bathing, cleaning, laundry, etc. She is requesting the nurse to come and see Thomas in the house. On arrival at this man’s room, the nurse finds him in bed. There is uneaten food on the locker next to him, his mouth is full of sores, and his legs are swollen and painful. A bedsore is threatening on his back, and his hygiene is poor. The man is depressed, and the room is dirty and smells bad. The man has been unemployed since he became ill. He states that his only help comes from the landlady and sometimes friends. His relatives live far away and he has not seen them for two years since he came to work as a migrant labourer. Thomas, however, indicates that he has a sister who used to get along with him until they quarrelled about his sexual behaviour. He does not know what to do. • What could the problem have been with the healthcare delivery system and what should have been done before this date? • What other data will you collect from the man about his family and significant others? ➙

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• What type of assistance will this man need? Write a care plan for him based on the information given. • How could a hospital discharge plan have helped this man? • What questions will you have for the medical doctor?

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12

Maintaining patient safety

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate comprehension on the importance of ensuring a safe environment for a patient. • Identify and describe incidents affecting the safety of the patient, nurse, other healthcare workers and communities. • Describe the nursing interventions that can be implemented to prevent environmental risks and hazards in healthcare facilities like hospitals and clinics. • Correctly apply institutional policies regarding identification of patients, and safety of their persons as well as their property. • Correctly apply the National Core Standards of quality care to ensure the patient’s safety in the clinical area. • Correctly manage incidents and accidents compromising patient safety in the clinical area. • Demonstrate knowledge and insight into the legislative framework pertaining to patient safety in South Africa.

Key concepts and terminology Adverse event: An injury resulting from a medical intervention. Error: Failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim. Medico-legal hazard: A threat to the safety of all persons within a healthcare setting, including patients, personnel or visitors. Patient safety: Freedom from harm whilst receiving healthcare. Restraint: A restrictive device used to subdue and limit the physical activity of a patient. Safety: Care that minimises harm to patients and providers through both system effectiveness and individual performance.

Prerequisite knowledge The nurse should have knowledge of the following: • An understanding of microbiology

➙

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• Knowledge of infectious diseases • Knowledge of anatomy and physiology.

Medico-legal considerations • The South African Nursing Council regulation on the scope of practice for registered nurses requires the nurse to execute a programme of treatment or medication prescribed by a registered person, and further holds that the nurse is responsible for the treatment and care of the administration of medicine to a patient, including the monitoring of the patient’s vital signs and of his or her reaction to disease conditions, trauma, stress, anxiety and medication. • Hospital-acquired infection is a medico-legal hazard that should be avoided as it may not only be very costly to the organisation and to the patient, but may also compromise the quality of life of the patient as some infections become resistant to treatment.

Key ethical considerations • Healthcare facilities have a legal and moral obligation to provide a safe environment for healthcare providers, patients and their families, and the community as a whole. • Patients who, for their safety and that of others, require restraint must have this prescribed. The restraints must not be used longer than is necessary or be too tight, and the condition of the patient under restraints must be recorded four-hourly. The restraints must be released periodically to allow free movement, and if they are applied around the wrists, fingers or ankles, the skin must be inspected for trauma and to ensure that circulation is not impeded. • It is the right of patients to be informed about all procedures conducted on them, and it is their right to refuse treatment without repercussions. • All medication given to patients must be prescribed by a person registered to do so, and consent must be obtained from patients whenever possible for invasive procedures. • Healthcare providers must practise hand hygiene to prevent transmission of infection from patient to patient, healthcare provider to patient, and vice versa.

Essential health literacy • Patients and communities must be informed about the benefits of cleanliness in terms of personal and environmental hygiene. • Patients and communities must be informed about safety from injury and infection while in hospital and at home. The principles of hand hygiene to prevent crossinfection should be emphasised. Patients must make hand washing a habit while in the healthcare facility and continue with this after discharge. ➙

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• Other simple measures to prevent cross-infection include covering the mouth and nose with a tissue when sneezing and coughing, and disposing of the tissue by flushing it down the toilet or putting it into a sealed plastic bag for incineration at a later time.

Introduction A safe environment is desirable for both the patient and the nurse. Quality patient care requires nurses to possess the knowledge and an understanding of a safe healthcare environment in order to assess it for threats and render it safe for all. A safe environment for patients is one which encompasses caring and compassion as core values. Safe, effective and quality patient care is an ideal to which the majority of nurses aspire to provide nursing care. However, safety is often compromised, with detrimental effects to the patient or the nurse. Safety in healthcare has become a serious concern worldwide. This chapter will focus on patient safety, taking into account the reduction of physical hazards as well as the reduction of transmission of pathogenic microorganisms. The ethical-legal framework pertaining to patient safety will also be highlighted.

Overview of general aspects of safety in a healthcare institution Studies in quality care indicate that patient safety is a global concern. Safety in a healthcare institution is an essential consideration in every aspect of patient care. Safety means a safe clinical environment for all healthcare workers, other personnel in the institution, patients, their good names and property, as well as visitors to the institution at any given time. In South Africa everyone has a constitutional right to an environment that is not harmful to their health or wellbeing, and to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures.

Patient safety in the healthcare institution In order to promote and maintain a culture of safety, nurses need to focus on a conscious reduction of risks, injury, infection and adverse effects of all medical and therapeutic interventions of all forms including medications. Specific activities are designed to engender safety through the lifespan, from the youngest patient to the oldest. Provision of a safe environment for patients is a core value in nursing practice. To err is human; however, safe behaviours can be learnt and integrated into nursing practice. Accountability to safe, effective and competent care should be acknowledged as an acceptable standard of care. The nurse is in a key position to play a significant role in ensuring that this standard of safe patient care is maintained and upheld.

Nursing and safety Traditionally, patient safety in nursing focused mainly on the following, among other things: • Using the bedrails properly to ensure that the patient does not fall out of bed • Preventing medication errors by using the ‘five rights’ of medication (see the clinical alert box on page 223 on the five Rs to be considered when giving medication). 212

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However, there is more to patient safety than these two aspects. Other important ones to consider include the following: Lack of a culture of safety in an institution is very often characterised by the following: • Lack of protocols or policies • Lack of teamwork, communication and safety culture • Inadequate proportion of health workers • Absence of reliable safety indicators • Lack of safety education • Lack of leadership in risk management. Sustained research on patient safety indicates the close relationship between quality care and patient safety. In providing a safe environment in patient care, nurses have to consider the national and international standards which highlight best practices in patient safety.

National standards of patient safety The Department of Health has published the National Core Standards for Health Establishments in South Africa (2011). The purpose of these standards, among others, is to ensure the provision of quality and safe care for patients. The core standards are developed into seven cross-cutting area or domains where service quality and safety may be at risk. These standards are based on the key priority areas that have been identified through surveys, as well as through media reports. Compliance with the standards is deemed as critical in improving the quality of healthcare services and reducing the risks associated with poor care and inadequate management. The key priorities are the following: • Improving staff values and attitudes • Reducing waiting times • Improving cleanliness • Improving patient safety and security • Preventing and controlling infection • Ensuring the availability of medicines and supplies. Table 12.1 indicates the seven domains of the National Core Standards. Table 12.1  The seven domains of the National Core Standards Domain 1

Patients’ rights

Domain 2

Patient safety, clinical governance and care

Domain 3

Clinical support services

Domain 4

Public health

Domain 5

Leadership, corporate governance

Domain 6

Operational management

Domain 7

Facilities and infrastructure

Source: National Core Standards for Health Establishments in South Africa (2011)

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The first three domains (Patients’ rights; Patient safety, clinical governance and care; and Clinical support services) relate to the core business of the health delivery system, whereas the remaining four domains pertain to the support system that ensures that the core business is achieved by the staff. Delivery of quality care will be measured against the implementation of these standards. Domain 2 is described in relation to the standards to be maintained in order to provide patient safety. Table 12.2 provides the summary.

Patient safety, clinical governance and clinical care This domain covers how to: • ensure quality nursing and clinical care. and ethical practice • reduce unintended harm to healthcare users or patients in identified cases of greater clinical risk • prevent or manage problems or adverse events, including healthcare-associated infections • support any affected patients. Table 12.2  Standards in patient safety, clinical governance and clinical care Sub-domain

Standard

Patient care

• Patients’ recovery care and treatment follows nursing protocols, meets their basic needs and contributes to their recovery

Clinical management of priority health conditions

• Care provided contributes positively to national priorities, including the United Nations Millennium Development Goals for maternal and child health, HIV and tuberculosis

Clinical leadership

• Doctors and nurses and other health professionals constantly work to improve the care they provide through proper support systems

Clinical risk

• Clinical risk identification and analysis take place in every ward/ unit to prevent patient safety incidents • Patients with special needs or at high risk, such as pregnant mothers, children, the mentally ill or the elderly, receive special attention • Safety protocols are in place to protect patients undergoing highrisk procedures such as surgery, blood transfusion and resuscitation

Adverse events

• Adverse events or patient safety incidents are promptly identified and managed to minimise patient harm and suffering • Adverse events are routinely analysed and managed to prevent recurrence, and managers learn from mistakes

Infection prevention and control

• An infection prevention and control programme is in place to reduce healthcare-associated infections • Specific precautions are taken to prevent the spread of respiratory infections • Standard precautions are applied to prevent healthcare-associated infections • Strict infection control practices are observed in the designated infant feed preparation areas

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International standards of patient safety in nursing practice As patient safety is a global concern, it has received attention internationally over the years, and nurses are regarded as the key role players in enhancing patient safety. The International Council of Nurses (ICN) adopted a Position Statement on Safety in 2012, which states the following: The ICN believes nurses and national nurses’ associations have a responsibility to: • Inform patients and families of potential risks • Report adverse events to the appropriate authorities promptly • Take an active role in assessing the safety and quality of care • Improve communication with patients and other healthcare professionals • Lobby for adequate staffing levels • Support measures that improve patient safety • Promote rigorous infection control programmes • Lobby for standardized treatment policies and protocols that minimize errors • Liaise with the professional bodies representing pharmacists, physicians and others to improve packaging and labelling of medications • Collaborate with national reporting systems to record, analyze and learn from adverse events • Develop mechanisms, for example through accreditation, to recognize the characteristics of healthcare providers that offer a benchmark for excellence in patient safety.

These responsibilities are available to all nurses when needing support in situations where safety is an issue (ICN 2012: 2). The international literature also reports on research studies and best practices regarding patient safety. Of importance is the challenge faced by nursing education to teach students about patient safety early in their training, so as to successfully develop a culture of patient safety. One of the competencies that have been identified for a nurse practitioner nationally and internationally is that of patient safety. (Other competencies are discussed elsewhere in this book.) Nurse educators have a responsibility to ensure that student nurses are competent in minimising the risk of harm to patients and providers through individual performance and system effectiveness. Related to this competence, the student needs to demonstrate the appropriate knowledge, attitudes or behaviours as well as the skills. Competencies required for patient safety are provided in Table 12.3. Table 12.3  Competencies for patient safety SAFETY: The nurse will minimise the risk of harm to patients and providers through individual performance and system effectiveness. Knowledge

Attitudes, behaviour

Skills

• Describes factors that create a culture of safety

• Recognises the importance of communication with the patient, family

• Participates in data collection to facilitate effective transfer of patient care ➙

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Knowledge

Attitudes, behaviour

Skills

• Delineates general categories of errors and hazards in healthcare • Identifies human factors and basic safety design principles that affect unsafe practices

and healthcare team members regarding safety and adverse events • Appreciates the cognitive and physical limitations of human performance

responsibility to others in the healthcare team • Uses organisational error reporting system successfully • Communicates observations or concerns related to hazards and errors to patients, families and/ or healthcare team members • Demonstrates the effective use of technology and standardised practices and protocols that support safe practice

In keeping with international norms and standards, the South African Nursing Council has announced the introduction of new qualifications for nurses which will be competency based. Nursing education internationally has been providing competencybased nursing curricular models in pre-registration nursing programmes. Over and above the generic competencies for a registered nurse practitioner, an initiative in the United States further zooms in specifically on the patient safety aspect, and is referred to as Quality Safety Education for Nurses (QSEN). Mastery of the following competencies have been identified as important in the preparation of professional nurses: • Patient-centred care • Teamwork and collaboration • Evidence-based care (EBP) • Quality improvement • Safety • Informatics.

Common safety issues in healthcare Several aspects regarding safety are identified as risk factors for both the patient and the care provider. Some patients are more vulnerable than others, and nurses invariably are always at risk, as nursing is a risk-laden occupation. Firstly, factors affecting patients’ potential for accidents are discussed.

Factors affecting patients’ potential for accidents The factors include the following: Altered sensory perception

Any decrease or loss of sensory faculties such as hearing, sight, smell or touch reduces a patient’s awareness of the environment and increases the safety risk to which that patient is exposed. The following factors should be taken into account: 216

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• Hearing: A patient who cannot hear may be unable to understand what is happening in the clinical area, and will be unable to hear people approach, which may expose him or her to hazards. • Sight: If a patient’s sight is severely diminished or he or she is blind, that patient may have difficulty in coping in a new or strange environment. A patient who is visually impaired may bump into objects, trip or fall in unfamiliar places or areas. • Smell: Without a sense of smell, a patient might not be able to smell toxic gases or smoke from smouldering fires. • Touch: A patient whose nervous system has been compromised and whose sense of touch is diminished is more prone to injury. Tissue damage through pressure has the potential for necrosis and contractures as the feelings of pain and discomfort that normally act as a warning of impending tissue damage are absent or blunted. Impairment of awareness

Those patients with impairment in their awareness also require special attention: • Disorientation: Patients may not be fully aware of their surroundings because they are semi-conscious, unconscious or confused. An unconscious person is more vulnerable to safety risks and injuries. This change in perception may adversely alter the judgement of such patients regarding safety measures, and expose them to risks and accidents. • Age: Infants, toddlers and young children are at risk because they are active and adventurous but too young to understand the dangers that surround them. Most home accidents occur in this age group, for example falls from beds or down stairs, burns and scalding, electrical hazards, drowning and choking on small objects. Adult supervision is important in preventing such accidents. The elderly are more vulnerable to accidents because of diminished function, poor vision, impaired mobility and mental confusion. Common safety risks include falls on slippery or uneven floors. • Emotional state: Anger, anxiety, depression and shock are all emotions that can unsettle patients, causing them to behave irrationally and thus make them vulnerable to accidents. Mobility

Patients whose balance or co-ordination is affected by disease, muscle weakness or paralysis, or are not able to carry out normal activities due to illness are prone to falls and may need the assistance of crutches, a walker or a walking stick. Patients who are immobile are also prone to bedsores or decubitus ulcers (see Chapter 25). Lifestyle

Lifestyle practice can increase a person’s risk of injury. Alcohol and drug use may enhance reckless and unsafe behaviours, leading to various safety risks or injuries. Patients may be used to an independent lifestyle and, because they resent being dependent on others, may attempt things that they cannot manage, for example getting out of bed unaided and risking a fall.

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Communication

The inability to communicate clearly with one another may place patients at risk simply because they do not understand the nurses’ instructions. A patient who is illiterate will be unable to read instructions, for example ‘nil per mouth’. A language barrier may exist, either because the nurse talks a different language from that of the patient or the terms used are unfamiliar, or the nurses are too technical and cannot be understood by the patient. A patient may be aphasic and unable to communicate verbally.

Identification and management of risks in the healthcare environment As indicated earlier, incidents in a healthcare environment can compromise the safety of patients and nurses. It is therefore important for nurses to plan the care of patients in such a way that those incidents are prevented or at least minimised. Risks in health care are categorised according to their causative agents; patient driven or in relation to therapeutic procedures or equipment used. • Patient-driven incidents: These occur as a result of the behaviour of the patient, for example self-inflicted injuries, cuts and bruises, poisoning, burns, etc. • Therapeutic procedure incidents: These occur while therapy or care is being given, for example falls while transferring the patient, medication errors, contamination of sterile fields, incompetent and unsafe performance procedures. • Equipment incidents: This refers to the malfunction or improper use of medical equipment, and power failures (electricity is needed for the use of some equipment, for example incubators).

Existing safety knowledge Most patients are knowledgeable about common safety measures. Thorough assessment should enable the nurse to identify knowledge deficits and plan interventions accordingly. The general principles of planning for patient safety are outlined in the box below.

General principles of planning for patient safety Vigilance is the first step in the prevention of medico-legal hazards in a nursing unit: • Apply general safety precautions and measures to prevent accidents or adverse incidents. • Ensure prompt and complete reporting of all accidents or breaches of safety in a nursing unit. • Apply appropriate measures to rescue patients from hazardous situations, for example fire. • Ensure that there is an appropriate disaster plan in the unit or institution that is known to all members. • Ensure that patients are well informed about their treatment regarding the effects, potential accidents and the prevention thereof. • Ensure that patient safety is taken into account in all the individual nursing care plans. • Assess and maintain the general safety of the environment at all times. • Ensure proper maintenance of equipment.

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Identification and management of risks Infections Infection control and standard precautions

Prevention and control of infection is one of the most important nursing roles regarding the safety of the patient. The transmission of infection from patient to patient or nurse to patient, or vice versa, in healthcare institutions is a medico-legal risk and a serious problem. Healthcare institutions are places where sick people congregate, and infections are easily passed from one patient to the next. Hospital-acquired or nosocomial infection causes increased morbidity and mortality among patients, and can also impact on their stay and the cost of it. The fact is that the environment of the healthcare institution is colonised by the multiple organisms carried by patients, and these may easily be transmitted to newly admitted patients. Many of these hospital-based organisms are resistant to ordinary antimicrobial therapy and can cause serious and life-threatening infections in susceptible patients, therefore infection control refers to all the measures applied in a nursing unit to prevent infections from occurring by removing the source or destroying it. A detailed discussion on infection control can be found in Chapter 13. Reasons why patients in hospital are more vulnerable to infections

The following reasons are advanced: • A sick patient has a lowered resistance and is more vulnerable to infection, especially where the primary defences are inadequate, for example a break in the continuity of the skin, trauma, stasis of body fluids, changes in the pH of body secretions, as well as in altered peristalsis. • A patient may have inadequate secondary defences, as in immunosuppression. • A patient may be nutritionally compromised due to illness. • The very elderly and the very young are more susceptible to infection. An infant’s immune system is immature, while the elderly have a diminished immune response as a result of the ageing process itself. • Invasive procedures and some pharmaceutical agents can increase vulnerability. • Patients come into close proximity with a large variety of other sick people who may be carrying a variety of micro-organisms. Nurses must therefore be thoroughly conversant with the principles of prevention in relation to cross-infection and must apply them diligently when working with patients. Routes of transmission

There are several ways in which pathogenic organisms can be transmitted. The most common routes are the following: • Contact transmission: This is the most frequent and therefore the most important means of transmission to consider when preventing infection. Contact transmission includes direct, indirect and droplet contact. • Vehicle transmission: A vehicle is an agent or a medium that carries the pathogen, for example blood, water or food. Viruses such as HIV and hepatitis B can be transported by blood. 219

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• Airborne transmission: Micro-organisms may float freely in the atmosphere or attach to dust particles. They may then be inhaled by or deposited on a susceptible host, and an infection results. • Vector transmission: Animals or insects, for example mosquitoes and rats, may carry the pathogen from one host to another or to another transport medium. Principles of infection control include the following: • Remove the source of infection by establishing and maintaining a hygienic environment through sterilising, disinfecting and cleaning (good housekeeping), and treating the infected patient. • Block the routes of transfer of micro-organisms by applying barrier nursing measures; that is, by isolating the infected susceptible patients and staff, practising aseptic techniques, and ensuring high standards of personal hygiene of staff. • Increase patients’ resistance by improving nutrition, rest and exercise. The Standard Precautions

The Standard Precautions, previously referred to as the ‘Universal Precautions of Infection Control’, are measures designed to reduce the risk of transmitting bloodborne viruses to healthcare workers. The guidelines are intended to minimise the risk of coming into contact with body fluids such as blood, urine, faeces and other body secretions. Precautions are applied when coming into contact with every patient, in all settings, regardless of the diagnosis. The most effective method of preventing and reducing infection is hand hygiene, which is a broad term referring to hand washing, scrubbing, spraying and wearing gloves, which must be changed between patients and activities (see box).

Minimising cross-infection • Perform hand hygiene between hand contacts, after contact with blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated items. • Wear gloves when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated items. • Remove gloves and perform hand hygiene between the care of every patient. • Wear a mask, eye protection or a face shield in case of secretions generating splashes or sprays of blood or body fluids. • Cover all wounds with a waterproof dressing. • Clean and reprocess patient-care equipment properly, and discard single-use items. • Place contaminated linen in a leak-proof bag to prevent skin and mucous membrane exposure and contact. • Discard all sharp instruments and needles in a puncture-resistant container (needles should be discarded uncapped, or use a mechanical device for recapping). • Provide a private room if a patient’s hygiene is unacceptable. • Ensure that patients cover their nose/mouth when coughing or sneezing; use disposable tissues to remove respiratory secretions, and make sure they are incinerated safely.

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Hand washing or alcohol rubs (eg with paediatric hand spray) is undertaken in the following situations: • Before direct contact with patients or their records • Before putting on sterile gloves and before doing any invasive procedures such as, for example, inserting indwelling urinary catheters, peripheral vascular catheters, etc • After contact with a patient’s intact skin, for example when taking a pulse or blood pressure, or when lifting a patient • After contact with body fluids, excretions or mucous membrane, etc, even when the hands are not visibly soiled • When moving from a contaminated body site to a clean one during care • After contact with inanimate objects (including medical equipment) in the vicinity of the patient • After removing gloves. NB! For hand washing see Chapter 13 on infection control. Principles of wearing gowns, masks and gloves

The correct use of masks, gowns and gloves is essential in order to prevent the spread of infection. All staff, including doctors, paramedical staff and cleaners, must be taught the correct method of using gowns, gloves and masks. It is very important to explain to patients the reason for isolation and to ensure good communication with them at all times, as this secures their co-operation. The principles of wearing gowns, masks and gloves include the following: • Gowns –– Handle on the inside only. The outside is contaminated by contact with the patient. –– The gown must cover the nurse’s uniform. –– The gown must be properly secured/fastened. –– When removing the gown, only the inside should be touched. –– Wet or soiled gowns should be changed. –– Always wash hands before and after taking the gown off. • Masks –– The hands should be washed before donning the mask and before removing it. –– The mask should fit properly over the nose. Spectacles may be allowed to rest over the nose piece of the mask to prevent misting. –– The mask should not be touched while it is worn. –– The mask should be changed if it becomes soiled or wet. –– Once masks have been removed, they must be properly disposed of. –– The same mask should not be worn twice. Once taken off, it must be discarded. • Gloves –– Only the inside of the glove should be handled. The outside of the glove is regarded as contaminated when the gloves are being worn as part of isolation precautions. 221

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–– Gloves should be donned last, after the gown and mask have been put on. –– A new pair of gloves should be put on if the first pair is punctured or torn. –– When removing gloves, pull them off inside out so that the outside is not touched.

Safe administration of medication Safe administration of medication begins with a legally valid prescription by a doctor or other registered person. The accurate interpretation of the prescription and the safe administration of medication is also very important. Principles of safe administration of medication Legal validity of a prescription is ensured by the presence of the following: • The full name of the patient • The date and time of administration • The frequency of administration • The generic name of the drug • The dosage to be given • The signature and designation of the doctor, the legibility of the entire prescription, and the date. A nurse should always be certain that he or she understands the prescription and the method and route in which the medication is to be given. A nurse should never give any medication to a patient if he or she is unsure of the order. Nurses have a right to question any order that they cannot read or understand, or which they consider to be incorrect. The accountability for the execution of the prescription rests with the nurse. Type of order

The type of order is often indicated with abbreviations. Some of the commonly used ones include the following: Abbreviation

Meaning

a.c. (ante cibum)

before food

ad lib

as much as desired

b.d.

twice a day

c. (cum)

with

c.m. (cres mane)

tomorrow morning

ex aqua

with water

mane

in the morning

o.m. (omne mane)

every morning

per os

orally (by mouth)

p.c. (post cibum)

after food

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Abbreviation

Meaning

p.r.n. (pro re nata)

when necessary

q.h.

every hour (hourly)

q.i.d. or q4h

four hourly

stat (statim)

immediately

t.i.d.

three times a day

t.d.s.

three times a day by mouth

Medication must be given within 30 minutes of the time specified on the prescription. The exception to this is pre-operative medication, which must be given exactly as ordered. Dosages

It is essential for nurses to understand the dosages of the drugs that they administer to patients and how these dosages are calculated. Some drugs require the use of a protocol. Because of the dangers inherent in the administration of medications and the high probability of mistakes occurring, nurses should always check the dosage, route of administration and manner of administration with another colleague. If a nurse is at all unsure of a calculation, this should be checked with the charge nurse or a competent colleague. Knowledge of the drug administered

In order to be able to monitor a patient’s response to the medication, the nurse must be aware of the expected beneficial effects of the medication, side effects and adverse reactions. Ensure that the route used is correct for the drug; for example, pessaries are not given orally. Allergies, side effects and adverse reactions

Before giving any new drug to a patient, nurses should check the assessment record for any allergies, side effects or adverse reactions that have occurred in the past. The nurse should recheck with the patient (if conscious) before giving the medication to confirm the identification of the patient.

Clinical alert! Nurses should consider the five Rs when administering medications: • The right drug • The right dose • The right route • The right time • The right patient.

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Other safety precautions regarding medication

Other safety precautions regarding medication include the following: • Do not use medicines from unmarked or illegally marked containers. Also, do not use medicines that are discoloured or cloudy. Medicines that have formed sediment should also not be used unless they require shaking before administration, as is the case with emulsions. Do not administer expired drugs to patients. They should be returned to the pharmacy. • Medicines must not be left at the bedside of patients. The exception to this rule is patients who take medication p.r.n. (when necessary) – for example nitroglycerin preparations or antacids – or patients who are on medication for their own specific use, for example eye ointments, inhalants or lotions. Check the hospital/provincial policy regarding this practice. • Although patients may be encouraged, in some institutions, to be responsible for their own medication administration, the nurse remains responsible for the safety of the patient. He or she must, therefore, be satisfied that the patient is able to cope with this responsibility. The nurse also remains responsible to ensure that the patient has taken the medication and has to document that as well. • Medicines must be kept out of reach of children and other patients, especially when patients are responsible for their own medication. • Special precautions must be taken with some drugs, for example checking and recording the pulse before giving digitalis.

Safe storage and control of medications • Keep all medication in locked cupboards or medicine trolleys. Never leave an open medicine trolley unattended. • Medicines for external use must be kept in a locked cupboard and separate from those for internal use. • Medicines should be stored at the temperature recommended by the manufacturer. • Never decant medicines from one container into another. • Labels indicating the name of the drug and instruction for administration must be clear, and not stained, usually by the medicine mixture, for example ferrous sulphate. • In terms of legislation, special controls are required for Schedule 5, 6 and 7 drugs, which must be adhered to. Poisons Apart from medicines, many of the substances used in an average clinical area in a healthcare institution are poisonous. The list includes substances used for cleaning and disinfection. Safety measures that should be adhered to for the prevention of poisoning are the following: • Keep all poisonous substances in a lockable cupboard, out of reach of all patients especially children. • All chemicals must be stored in bottles that are clearly labelled with the name of the chemical and the strength of the solution. • The bottles should be clearly marked POISON, with a lid that is tightly closed when not in use. 224

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• Poisons must never be decanted into other bottles. Chemicals for use in healthcare institutions should be mixed and dispensed by the pharmacist ready for use, for example Savlon. This prevents damage of a patient’s skin by high-strength solutions that have been incorrectly mixed. If solutions have to be mixed by the nurse, he or she must read the instructions carefully, wear gloves while mixing, and check calculations for dilution with a colleague.

Falls Falls are a common cause of injury to patients in healthcare institutions, and frequently result in legal action being taken against such institutions. The risk for falls increases with advancing age, and in confused and disoriented patients, as well as those who are attached to equipment, taking medication that causes cognitive alteration, or who fail the ‘get-up-and-go’ test. (See the box below.) The risks for falls are reduced by the following: • There must be vigilance and adequate supervision of all patients. • There must be effective orientation of all patients to the environment, call system, etc. • Cot sides should be used to prevent restless or confused patients from falling out of bed. In some institutions it is policy that any patient over 70 years of age should be nursed in a cot-bed with the sides up, particularly at night. However, thorough assessment of the mental capacity of the patient to understand the rationale for the use of cot sides should be ascertained before applying them, as some patients have been known to jump over the cot sides, sustaining serious injuries. • Frail, weak or elderly patients should not be allowed to get out of bed without assistance. Beds in healthcare institutions are high, and it is very easy for a patient to fall from a high bed. • Proper use of sedation and/or a prescribed restraint should be used for restless patients who may be inclined to try to get up and wander about if not sedated or restrained. • Patients who are weak and ill should always be assisted when ambulating or moving from a bed to a chair, or back again. • Loose rugs and slippery or highly polished floors should be avoided. Any spills on the floor should be wiped dry immediately. • Nurses should avoid moving patients unaided if at all possible, as this may result in a patient falling to the floor and hurting him- or herself.

Timed get-up-and-go test (TGUGT) This test is used to assess functional mobility. • The patient is timed while moving from a seated position to a standing one, walking three metres, returning to the chair and sitting. • Patients should be able to perform this test in 10 seconds or less. • Those that require 20 seconds or more are considered to have mobility deficits and should be closely monitored for falls.

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Restraints Restraints are protective devices that are used to limit the physical activity of a patient or to immobilise an extremity. Restraints may either be physical or chemical: • Physical restraints reduce the patient’s movement through the application of a device. A doctor’s prescription is usually required for the application of a physical restraint, followed by meticulous monitoring and documentation by the nurse. • Chemical restraints are medications used to control the patient’s behaviour. Commonly used chemical restraints include anxiolytics and sedatives, and a mild sedative may be prescribed to calm the patient. However, there may be times when sedation is contraindicated, and the only way to protect a patient is to use physical restraints. All people naturally resist restraint of any kind as it interferes with their right to move about freely. For this reason, restraints are used, especially in adults, as a last resort and with great circumspection. In all cases, the nurse should first try to calmly explain the reasons for the restraint, irrespective of the mental state of the patient. This section will focus on the common types of physical restraints. Restraints are used in the following cases, among others: • To protect the patient, for example to prevent a patient from falling out of a bed or chair • To allow for treatment in a safe environment, for example while intravenous therapy is running • To reduce the risk of injury to others, for example to prevent a confused patient from hitting nursing staff or other patients. Medico-legal implications of restraints

Mechanical means of bodily restraint may be used only for the purposes of surgical or medical treatment or to prevent a patient from injuring him- or herself, or others. The doctor must prescribe the type of restraint and the reasons for using it. If, however, there is any chance that a patient may remove essential items such as a central line or an endotracheal tube, thereby creating a potentially life-threatening situation, the nurse should not hesitate to use restraints and obtain the prescription later. If a patient is in full possession of his or her faculties, restraint may be viewed as assault, and a charge may be laid against the hospital personnel. Restrained patients often become more confused, restless and anxious than before, and they are more dependent on nursing care. It is therefore important to assess patients thoroughly and carefully before restraining them. Common types of restraint

The following types of restraint may be used: • Belt restraints: These are applied to prevent patients from falling off a narrow trolley, or an X-ray or theatre table. They may also be used to keep very weak, elderly or frail patients from falling out of a chair. The body of the patient is usually strapped onto the bed or stretcher with a belt.

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• Wrist restraints: These are applied to prevent confused patients, infants and children from removing essential lines, tubes, wires or dressings. They may also be used to prevent such patients from scratching or picking at wounds. Such restraints may consist of crêpe bandages, or readymade wrist straps may be used. • ‘Boxing gloves’ or mittens: These are applied for the same reasons as wrist restraints, but are less restrictive. A very restless patient may still be able to remove lines and tubes. ‘Boxing gloves’ must be firmly applied but must not be too tight, or circulation to the fingers may be compromised. Digits may also be injured if the patient is able to poke a finger through the ‘boxing glove’. ‘Boxing gloves’ should be taken off and re-applied every four to six hours to allow the hands and fingers to be cleaned and exercised. • Finger restraints: These are applied for the same reasons as wrist restraints or ‘boxing gloves’, but they are more comfortable. It is quite easy for a patient to remove finger restraints, so the nurse needs to be vigilant. These may also be used as splints when fingers need to be immobilised. • Mummy restraint, or restraining sheet or blanket: This is a blanket or sheet that is folded around a child to limit movement. Mummy restraints are used when performing procedures on children.

Wrist restraints

Gloves or mittens

Finger restraint

Clinical alert! Restraints MUST be prescribed by a doctor.

A restraining sheet

Figure 12.1  Various restraints

Principles of using restraints

• Explain the reason for using a restraint to the patient even if the patient does not appear to understand you. Reassure the patient frequently, as well as the significant others. • Choose the restraint to suit the age and the condition of the patient. Allow him or her as much movement as possible. • If the patient is restless, confused or aggressive, ask for help to apply the restraint. • Apply the restraint securely but do not cut off circulation. • Pad bony prominences before applying the restraint to prevent friction to the underlying skin. • Use knots that can be released quickly in an emergency. Do not use knots that will pull and tighten the restraint. The best knot to use is the clove hitch. 227

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• Remove limb restraints every two to four hours. Provide skin care and put the restricted limbs through a full range of movements. Reposition the patient. • Perform skin assessment, circulation and neurological test every two hours, checking the skin colour, sensation, temperature, motion and capillary refill in the area distal to the restraint. • Do not leave the patient unattended while the restraint is temporarily removed. • Report any change in skin colour or condition, for example blue or white skin. • Record and report any break in the skin. • While the restraint is on, keep the patient’s limbs in a position of normal function. • A daily record of restraints must be kept. The type of restraint used, the reasons for use and the name of the consenting doctor must be recorded in the patient’s notes. • In units where it is frequently necessary to restrain patients, such as intensive care units, a protocol may be used which has been drawn up by the medical practitioner in charge of the unit.

Clinical alert! Always remove the restraint at the earliest possible opportunity.

Safety of the person, reputation and possessions of patients Ensuring the safety of the reputation and possessions of patients is a major professional obligation in terms of professional legislation and ethical codes. The safety of patients’ possessions, however, is an aspect of patient safety that is frequently overlooked. The risk of civil liability suits against healthcare institutions due to patients’ possessions having been lost or stolen can be minimised if safety measures are followed. While a patient is in the care of the nurse in a healthcare institution, the nurse is responsible for ensuring the safekeeping of patients’ property as far as possible. Patients have the right to claim compensation from the hospital/clinic authorities if they can prove that their property was lost as a result of negligence by the staff of the healthcare institution. Each healthcare institution will have its own policy regarding care of patients’ possessions, and nurses must function within the policies of their employing institution. Many healthcare institutions will not accept responsibility for patients’ possessions if they believe this to be too risky or too costly. When such an exercise is undertaken, patients are asked to sign an indemnity form releasing the healthcare institution from this responsibility.

On admission Patients may keep personal items in their bedside locker, such as toiletries, spare nightclothes, underwear, dressing gown and slippers, tissues, reading material, sweets and fruit, if allowed. Nurses must explain to patients, however, that the healthcare institution cannot accept responsibility for these items and that they are kept at their own risk. If a patient’s clothing and valuables are taken home by a friend or relative, this must be recorded in the admission book or in a separate kit book, along with the name of the person who took them. In some institutions, however, patients’ clothing 228

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may be stored in a locked cupboard or in their bedside locker under their own care and at their own risk. Clothing may also be stored in a locked kit room or cupboard set aside for that purpose.

Kitting of clothes to be locked in a kit cupboard/room • Each item of clothing is carefully described and listed in a kit book. Do not use evaluative descriptions for clothing, for example recording a brown jacket as ‘an expensive brown leather jacket’. • The patient signs to verify the accuracy of the inventory. The nurse witnesses the signature. • All the items of clothing are carefully labelled, hung on hangers or placed in the patient’s bag or suitcase, or into labelled bags, and kept locked in the kit room. Care of money and valuables Following are a few general principles relating to the care of money and valuables in a healthcare institution. Money, other than small change, should never be kept at the bedside, but should preferably be sent home with relatives. If the valuables cannot be sent home, the following guidelines can be followed: • All valuables are removed, itemised and signed for in the valuables book. They are placed in an envelope and locked away. • If rings cannot be removed, they are covered with tape, which is recorded in the patient’s file and on the theatre forms. • Valuables are given back to the patient when he or she returns from theatre and is in an alert enough state to be able to check and sign for them. Unconscious or disoriented patients All possessions, except necessary toiletries and bed-wear, are kitted or locked in the safe and/or a valuables cupboard. It is essential that witnesses are present and that they sign the property books. The reason for the absence of the patient’s signature must be recorded. The patient’s possessions may be sent home, in which case the family must check the clothing and valuables and sign for them. Patients going to theatre • Remove spectacles, contact lenses, wigs, hairpieces, artificial limbs and dentures. (Some anaesthetists prefer dentures to be left in position – check the instructions.) To prevent embarrassment, these items are removed immediately before going to theatre. • Dentures are cleaned and placed in a clean bowl in the bedside locker.

Conclusion Patient safety in a healthcare facility includes the safety and security of his or her person, good name or reputation, as well as his or her belongings. The provision of safe patient care is a professional obligation of nurses, hence it is regarded as a nursing competency. Threats to patient safety may include various injuries as a result of compromised care given to patients, falls due to a variety of reasons, and being given the wrong treatment, especially medication. Vigilance and adequate patient supervision are key to mitigating threats to patient safety. 229

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Suggested activities for students Activity 12.1 Answer the following questions by choosing the most appropriate answer/s. 1. The doctor has prescribed a wrist restraint for a restless patient who is continuously pulling at his gastrostomy tube. The following outcomes assure the nurse that the intervention is successful to maintain the safety of the patient: a. The patient is agitated. b. The patient manages to free his hand and pulls the offending gastrostomy tube out. c. The patient verbalises that he understands the reason for the restraint. d. The patient demands to see the hospital superintendent. 2. Allowing one staff member to use another staff member’s access code on the computer to document the intake and output amounts of a patient is the foillowing: a. A good example of safe nursing practice b. Unsafe nursing practice c. A good example of team work, which should be encouraged d. Of no consequence. 3. In promoting patient safety, the nurse in a paediatric ward should allow a toddler who is potty trained to do the following: a. Remain alone in the bathroom in order to provide the child with privacy. b. Allow a 10-year-old patient to supervise the toddler. c. Leave the toddler alone in order to learn to be independent. d. Delegate a staff member to accompany the child to the bathroom. e. Let the toddler wear disposable nappies for easy care. 4. In a nursing unit, the risks for falls are greatly reduced by the following: a. Placing all confused patients in beds with cot sides up without any explanation b. Teaching patients to jump over spills on the floor, as stepping over them might cause falls c. Saving time and energy by not monitoring patients who are sedated d. Providing walkers and other equipment to assist patients in walking.

Activity 12.2 Read the following case study and answer the question below:

Case study Juanita Nkosi was discharged after spending a few days in hospital for minor surgery. She had recovered well and was eager to go back home to her family. Sister Zungu processed her discharge records and also gave the patient her prescribed medication to take home. However, she did not provide the patient with some pertinent information regarding the medication. Later during the day, the patient was re-admitted to the hospital after being involved in a motor-vehicle accident. The patient reported that she took some medication before she left the hospital and also reported that she fell asleep behind the wheel while driving home. • Design a discharge directive for Juanita Nkosi that will take her safety into account.

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chapter

13

Infection control in the unit

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate an understanding of infection control principles within a healthcare setting. • Describe the incidence and prevalence of hospital-acquired infections (HAIs) in the specific settings. • Identify the possible causes of infection in the healthcare setting. • Design the standards and protocols for infection control, including hand hygiene. • Demonstrate an understanding of the policies, procedures and infection control protocols.

Key concepts and terminology Hand hygiene: A general term referring to any action of hand cleansing (WHO 2009). Healthcare-associated infections: Infections that can be associated with healthcare in any setting rather than the hospital only. Hospital-acquired infection: An infection acquired from the hospital environment during a course of treatment while the patient is hospitalised or during a visit to hospital. Infection: The invasion of bodily tissue by pathogenic micro-organisms, resulting in tissue injury that can progress to disease. Infection control: All the measures applied in a nursing unit to prevent infections from occurring by removing the source or destroying it (Mogotlane, Chauke, Matlakala, Mokoena & Young 2013: 50). Infectious agent: The micro-organism which could be a bacterium, virus, fungus or parasite that can cause infection or disease (Singh, Gupta & Kant 2012: 16). Portal of entry: The path by which an infectious agent invades a susceptible host, and through which the infection transmission occurs, eg the respiratory tract, gastrointestinal tract and genitourinary tract or blood (Smeltzer, Bare, Hinkle & Cheever 2010: 2123). Portal of exit: The path/mode of exit for the micro-organism from one host to another, or to the environment for transmission to occur. Reservoir of infection: Any natural habitat such as an infected person, animal, fomites and the environment on which micro-organisms can grow and reproduce. Vector: Any agent, be it person, animal or micro-organism, that carries and transmits an infectious pathogen into another living organism.

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Prerequisite knowledge The nurse should have knowledge of the following: • An understanding of microbiology • Cell immunity and cell division • Infectious diseases • Anatomy and physiology.

Medico-legal considerations • Failure to adhere to infection-control standards while providing nursing care in a hospital is a malpractice which has serious consequences to patients who receive healthcare services in that facility. This failure can lead to prolonged illness, co-infections, prolonged hospital stays, financial drainage (on both the patient and the healthcare institution) and lack of trust by the consumers of healthcare services in a country. • Malpractice, negligence or poor attention to safety of patients and environments is a transgression that can lead to medico-legal incidents and complaints or civil claims by patients, and disciplinary action by the employer or the Nursing Council.

Key ethical considerations • Nurses have an ethical and professional obligation to prevent hospital-acquired and healthcare-associated infections at all times. • Nurses have an obligation to adhere to the principles of hand washing at all times. • Nurses have an obligation to adhere to universal precaution measures using the available resources while providing nursing care and conducting nursing procedures at the hospital. • Nurses as healthcare providers have an obligation to prevent nosocomial infections through practising proper medical and surgical aseptic techniques.

Key legal considerations Legislative framework There is a broad framework of legislation that provides guidance to all clinical practitioners on patient safety in any of the environments in which nurses may work. Nurses have an obligation to comply with the following Acts regulating practice: • The Constitution of the Republic of South Africa (1996), in Chapter 2 on the Bill of Rights, determines that everyone has a right to an environment that is not harmful to their health or wellbeing. • The Occupational Health and Safety Act 85 of 1993 section 8(1) specifically spells out the role of employers and workers on health and safety in institutions. One of the regulations in this Act is the Regulations for Hazardous Biological Agents, which has direct bearing on all people working in the health sector to protect them from any micro-organisms that can cause infection and disease. ➙

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• The National Health Act 61 of 2003 refers to the responsibility of healthcare establishments and their staff to ensure and maintain patient safety. • The Nursing Act 33 of 2005 and its regulations specifically prescribe the responsibility of nurses to establish and maintain, in the execution of the nursing regimen, an environment in which the physical and mental health of patients are promoted. This includes both physical and psychological safety, and implies that nurses should use their skills to assess the environment, identify actual or potential hazards, and take appropriate measures to eliminate them. • The Environmental Conservation Act 73 of 1989 as amended.

Essential health literacy • Advise nurses and patients to follow proper procedures and policies for infection control and hand hygiene. • Protective clothing such as gloves should not be substituted for hand washing. • Teach staff and patients on the use of protective clothing, and emphasise the principle of not repeating use and discarding to avoid contamination. • Provide written infection-control practices on notice-boards and walls such as for hand washing and wound dressing, and encourage staff, visitors and patients to follow the practices. • Conduct continuous in-service training for infection control and prevention to hospital staff and patients to improve adherence to infection-control practices.

Nursing implications General problems experienced in clinical practice that often lead to incidents or accidents involving patients include the following: • Negligence with regard to ordinary infection-control measures, for example sharing of towels; incorrect handling and disposal of dirty linen and waste; failure to wash hands between patients, and before and after performing nursing activities; inadequate hygiene of baths, toilets, bedpans and urinals • Disregard of patients’ requests for help to maintain hygiene • Failure to identify potential safety hazards related to waste disposal • Failure to be vigilant about patient safety, for example not applying effective infection-control practices • Failure to consult with colleagues and other professionals with regard to patient care and treatment, such as keeping a record of all hazardous incidents and writing reports on infection control when necessary.

Introduction The adherence to various precautions or barrier techniques to minimise infection risks to patients as well as to nurses while providing nursing care is essential. Historically, infectious diseases as the major cause of death among human beings dates back to 233

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the beginning of the 20th century. Conditions such as bubonic plague, also known as ‘Black Death’ are known to have contributed to the death of an estimated 75% of the populations of Asia and Europe (Schneider 2011: 131). Diseases and exposure to microorganisms may not always lead to infection. A healthy individual may be colonised without disease or carry infectious agents without overt symptoms, thus the need for immunisation against certain diseases, for example smallpox, vaccination against which was pioneered by Edward Jenner (1749–1823). The objective of infection control is to prevent transmission of infection from one person to another, and infection-control measures protect patients from opportunistic infections (Van Dyk 2012: 369). The control of infectious diseases should start with general public-health measures in areas such as purification of water, waste disposal, immunisation and personal hygiene. Nurses can play an important role in infection control and prevention by using appropriate barrier precautions, observing prudent hand hygiene, and ensuring the aseptic care of all wounds and invasive equipment to reduce infections in their patients (Smeltzer et al 2010: 2121).

Pathophysiology of infection A healthy person is protected from acquiring pathogens by virtue of natural barriers like skin, mucous membranes, humoral immunity and cellular immunity (Singh et al 2012: 3). An infection occurs when a pathogen penetrates the skin or mucous membrane barrier to reach interior body parts and cavities which are normally sterile. A reaction to such penetration is the development of clinical symptoms. For an infection to occur, the host must be susceptible – that is, without immunity to a particular pathogen. Infection does not develop until an individual becomes susceptible to the strength and number of micro-organisms (Smeltzer et al 2010: 2123). The micro-organisms can also attach loosely to the skin in dirt and grease or under fingernails, and they can be transmitted unless removed by proper hand washing. Patients who are hospitalised are susceptible to infections because their immune system is compromised, and also due to exposure to various medical treatments and invasive procedures.

Chain of infection The elements for an infection to occur are an infectious agent, a source of the infectious agent (reservoir), a susceptible host to receive the agent, and a way for the agent to be transmitted from the source to the host. The interaction among these elements is known as the chain of infection (Singh et al 2012: 16). An example would be as follows: • An infectious agent: dirt • Source of the agent: nurse’s hands and nails • A susceptible host to receive the agent: patient’s skin • A way for the agent to be transmitted from source to the host: touching the patient. Mode of transmission of infection The way in which the infectious agent moves from the reservoir to a susceptible host is called the mode of transmission. Infectious reservoirs thrive in healthcare settings, and may include everything from patients, visitors, healthcare staff members, medical equipment, food and water. The modes or routes of transmission are as follows:

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• Contact transmission This can be direct or indirect: –– Direct contact transmission involves proximity between the susceptible host and an infected person, such as touching during bedbath, or when performing patient care activities that require direct personal contact. –– Indirect contact transmission involves personal contact with inanimate objects such as contaminated needles, instruments and gloves that are not changed between patients. • Droplet transmission occurs when droplets containing micro-organisms from the source of infection are transmitted through the air to the host. Droplet infection could be through sneezing, coughing, talking or even splashing or spraying with contaminated material such as blood. • Vehicle transmission occurs through contaminated items such as water, fluid, medications, invasive devices and other equipment. • Airborne transmission occurs through the atmosphere, such as with the inhalation of infected dust particles. • Vector transmission is through animals such as rats, and insects such as mosquitoes and flies.

Risk factors for infection • Elderly patients and infants where resistance to infection is low because the immune system is compromised • Patients with: –– low resistance due to trauma, skin breaks, etc –– immune suppression –– nutritional compromise –– invasive procedures –– contact with other sick patients. Hospital-acquired infections Infectious diseases include, among other things, polio, Pott’s disease from tuberculosis (TB), tetanus, plague, typhus disease, syphilis, cholera, typhoid fever, smallpox, TB and anthrax. Hospital-acquired infections, also called nosocomial infections, develop during patient hospitalisation or a visit to hospital or other health facility (Damani 2012). Some nosocomial infections result from treatment and procedures rendered by healthcare practitioners, for example ventilator-associated pneumonia, TB, urinary tract infections, gastroenteritis, drug-resistant infections, fever of unknown origin, and bacterial infections such as methicillin-resistant Staphylococcus aureus (MRSA) (WHO 2009: 2). Nosocomial infections are said to be acquired at least 12 hours after admission. Hospital patients are more prone to developing infections either from an exogenous route, where sources of infection are acquired from the healthcare environment, equipment and healthcare workers; or via an endogenous route, where the source of infection is the patient’s own microflora (Damani 2012). Other causes of hospitalacquired infections include lack of hygiene, the increased use of outpatient treatment,

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the bypassing of natural body protective barriers by medically invasive procedures, and healthcare staff as vectors.

Principles of infection control Infection-control principles are written protocols and guidelines a nurse should follow in making sure that there is maximum control and prevention of patient infection in the process of nursing care. The following are the principles: • Remove the source of infection. • Block the routes of infection. • Increase the patient’s resistance. To minimise infection, the nurse should ensure proper hand hygiene through hand washing, donning gloves and hand spray. Wounds should be covered at all times, and during wound care and for other procedures, the nurse should wear protective clothing as directed. Barrier nursing and proper disposal of linen and waste are essential.

Guidelines for infection control Infection-control standards are scientifically proven guidelines to be followed by healthcare providers to safeguard their patients by controlling disease and preventing the spread of infection. Adherence to proper infection-control standards while providing care at the respective healthcare facilities is essential to minimise infection. The Centers for Disease Control and Prevention (CDC) developed guidelines for isolation practices in 1970, which led to universal precautions (UP) development in 1985, following the HIV epidemic. Body substance isolation (BSI) was then developed in 1987. The BSI are techniques to prevent and protect healthcare personnel from body substances including blood, semen, faeces, urine, sputum, saliva, wound drainage and other body fluids (Van Dyk 2012: 368; Daniels, Nosek & Nicoll 2007: 279). The CDC developed standard precautions in 2006. These are actions to be used with all patients to reduce the risk of transmission of disease or infection (Mogotlane, Manaka-Mkhwanazi, Mokoena, Chauke, Matlakala & Randa 2015: 41). These include hand washing; hand hygiene; the wearing of masks, eye protection (such as goggles and face shields), gloves and gowns; the use of linen containers and proper disposal of contaminated equipment in specially labelled bags; double bagging; and the disposal of sharps in correct puncture-proof containers. Contact precautions • Practise standard and isolation precautions. • Nurse the patient in a single room. • If no single room is available, nurse patients with similar diseases or infections together. • Wear protective clothing during contact with the patient. • Don personal protective clothing on entry to the room, and discard it before exit from the room to minimise the environmental spread of infection. Droplet precautions • Practise standard and isolation precautions. • Wear a mask during contact with the patient. 236

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• Put a mask or N95 respirator on the patient’s face when transported outside the room.

Airborne precautions • Practise standard and isolation precautions. • Keep the patient’s door closed at all times. Methods of infection prevention and control The two methods of infection control are medical and surgical asepsis. Medical asepsis

This is the clean technique aimed at the nurse’s effort in decreasing the number and spread of micro-organisms. It is based on the principles of simple, basic and obvious techniques expected to be done on a daily basis. Medical asepsis includes the following: • Cleaning: This is the removal of all foreign material such as soil and organic material from objects. Cleaning involves the use of water and mechanical action with or without detergents. Joseph Lister (1827–1912) described antiseptics and asepsis in cleaning of hospitals. This can be achieved by general ward cleaning through floor scrubbing and damp dusting of beds, cabins and sinks as basic routine activities to be done every morning before commencement of other activities. Nurses have a responsibility to develop cleaning procedures and guidelines to be followed by the staff responsible for daily cleaning of the unit and its equipment. The environment and equipment should be cleaned and disinfected using appropriate disinfection. • Sterilisation and disinfection: These are processes that eliminate many or all pathogenic micro-organisms on inanimate objects. Sterilisation is exposure to chemicals, ionising radiation, dry heat (eg an oven), or steam under pressure (eg autoclave or pressure cooking) in order to kill micro-organisms on equipment and surfaces (WHO 2000). Disinfection (the process defended by Robert Koch 1843– 1910) includes pasteurisation (the process invented by Louis Pasteur 1822–1895), boiling and chemical soaking. Nurses should ensure proper sterilisation of surgical equipment to be used in a well-disinfected environment to minimise the spread of pathogenic micro-organisms to patients. Disinfectants such as chlorine are the products of choice to minimise the spread of nosocomial infections (Humphreys, Finan, Rout, Hewitt, Thistlethwaite, Barnes & Pilling 2013: 127). Equipment should be properly washed, disinfected and sterilised, or discarded/disposed of according to standard precautionary measures. • Hand hygiene: The WHO (2009) considers hand hygiene to be the primary means necessary for reducing healthcare-associated infections (HCAIs). Micro-organisms can be directly transmitted to patients through touching, therefore proper hand hygiene or the use of gloves can interrupt this means of transmission. Factors related to good hand hygiene include adequate materials, adequate staffing, appropriately located hand-washing resources, and the availability of hand-washing materials such as soap and alcohol gels at the point of patient care (Damani 2012). Standard precautions for hand hygiene are hand washing, alcohol-based hand disinfection and the wearing of gloves. The WHO (2009) describes the ‘five moments of hand hygiene’, which specify when hand hygiene should be done. 237

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The ‘five moments of hand hygiene’ (WHO 2009) Hand hygiene should be done • before touching a patient • before a clean or aseptic procedure • after body fluid exposure risk • after touching a patient • after touching the patient’s surroundings.

Hand hygiene products as recommended by WHO (2009: 2) • Alcohol-based hand disinfectant: An alcohol-based gel to rub on the hands with the aim of removing dirt and decontaminating them • Alcohol-based (hand) rub: An alcohol-containing preparation (liquid, gel or foam) designed for application to the hands to inactivate micro-organisms and/or temporarily suppress their growth • Antimicrobial (medicated) soap: Soap (detergent) containing an antiseptic agent at a concentration sufficient to inactivate micro-organisms and/or temporarily suppress their growth • Antiseptic agent: An antimicrobial substance that inactivates micro-organisms or inhibits their growth on living tissues • Antiseptic hand wipes: A piece of fabric or paper pre-wetted with an antiseptic used for wiping hands to inactivate and/or remove microbial contamination, which may be considered as an alternative to washing hands with non-antimicrobial soap • Detergent: Compounds that possess a cleaning action • Plain soap: Detergents that contain no added antimicrobial agents, or may contain these solely as preservatives • Waterless antiseptic agent: An antiseptic agent (liquid, gel or foam) that does not require the use of exogenous water.

Hand hygiene practices as recommended by the WHO (2009) • Antiseptic hand washing: Washing hands with soap and water, or other detergents containing an antiseptic agent • Antiseptic hand rubbing: Applying an antiseptic hand rub to reduce or inhibit the growth of micro-organisms without the need for an exogenous source of water and requiring no rinsing or drying with towels or other devices • Hand antisepsis/decontamination/de-germing: Reducing or inhibiting the growth of micro-organisms by the application of an antiseptic hand rub or by performing an antiseptic hand wash • Hand care: Actions to reduce the risk of skin damage or irritation • Hand washing: Washing hands with plain or antimicrobial soap and water • Hand cleansing: Action of performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material and/or micro-organisms ➙

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• Hygienic hand antisepsis: Treatment of the hands with either an antiseptic hand rub or an antiseptic hand wash to reduce the transient microbial flora without necessarily affecting the resident skin flora.

• Barrier nursing: This is the nursing of patients in separate rooms and using personal protective clothing and equipment. For contact transmission-based precautions it is also called isolation nursing. Isolation was practised by Florence Nightingale (1820– 1910), who separated patients into different wards according to their diseases. During isolation, nurses should adhere to isolation precautionary measures designed to prevent the transmission of micro-organisms. Personal protective equipment used in barrier nursing includes facemasks, gloves, face shields, goggles, gowns, aprons, footwear, shoe covers and caps, depending on the disease. Protective clothing protects staff from micro-organisms, from the patients or from the environment, and vice versa, and therefore they should be properly donned and used to provide maximum protection. Surgical asepsis

Surgical asepsis is defined as the complete removal of micro-organisms and their spores from the surface of an object. Surgical asepsis is a sterile technique requiring nurses to use extra precautions above the general medical asepsis to eliminate microorganisms. The use of sterile techniques ensures that an environment is completely free from all micro-organisms. Sterile techniques include the creation of sterile fields by using sterile packs and sterile instruments; covering the patient with sterile drapes; and wearing sterile gowns, hats, gloves and face masks. The personnel who assist with sterile procedures should also perform surgical hand washing with antimicrobial agents and don gowns, masks and gloves.

Hand washing Hand washing is the application of soap and water to cleanse the hands. Adherence to and proper hand washing during nursing care will prevent general infections, nosocomial infections and HCAIs. Types of hand washing

Two types of hand washing are aseptic technique and surgical hand washing. Aseptic technique: This is hand washing using the following: • Plain soap: Hand washing should be done for at least 30 seconds. • Antiseptics: Hand washing is done using antiseptics such as Hibitane, Hibiscrub, Betadine and Savlon. • Alcohol hand rubs: Hand washing is done using waterless antiseptics such as chlorhexidine. Ignaz Semmelmeis (1818–1865) emphasised hand washing with a chloredine solution. Surgical hand washing: Surgical hand washing includes the following: • Scrubbing the hands to be sterile • Donning sterile gloves. 239

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Indications for hand washing The CDC (2011) guidelines for hand hygiene in healthcare settings recommend that hand washing be done as follows: • When hands are visibly dirty or contaminated with fluids or blood, wash with soap (antimicrobial or non-antimicrobial) and water. If hands are not visibly dirty, use an alcohol-based hand rub. • Wash or decontaminate the hands: –– before patient care –– between patient contacts –– before and after having direct contact with patients, including nappy changes –– before wearing sterile gloves, and after removing them –– before eating and after using the bathroom –– before eating, preparing food or feeding patients –– immediately after contact with blood or other body fluids –– after contact with surfaces, equipment, linen contaminated with blood or body fluids –– before and after invasive procedures in which the patient’s skin is punctured.

Standard precautions for infection control • Wash hands. • Wear gloves. • Wear a mask and eye protection, or a face shield. • Wear a gown or apron. • Ensure clean patient-care equipment and environment. • Dispose of soiled linen appropriately. • Dispose of needles and sharps according to occupational health standards. • Avoid sharing needles and syringes, and do not re-cap needles before disposal. • Use private rooms to isolate infectious patients.

Infection-control actions The hospital or healthcare service should have the following: • An infection prevention and control policy. This should include the use of antibiotic therapy. • Monitoring and evaluation system through surveillance, as suggested by Robert Koch (1843–1910). This will assist in detecting outbreaks at the onset and provide data to take actions to minimise infections. • Infection control committees which will take the lead in infection control and prevention in the hospital. The infection control committee should be made up of key personnel, including nurses from the healthcare facility departments. The committee members’ responsibilities should be to ensure the availability of appropriate supplies needed for infection control, investigate and report outbreaks of nosocomial infections. and assist in the development and update of infectioncontrol policies. 240

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• Procedure guidelines. These should incorporate infection-control practices and should be placed in strategic rooms in the various departments as a reference for healthcare personnel, patients and visitors.

Possible causes of failure to adhere to infection-control standards • Lack of or inadequate staffing • Improper education on infection control • Lack of equipment and supplies • Poor infrastructure • Lack of policies and guidelines.

Conclusion Nurses’ adherence to infection-control standards can help to minimise the onset and spread of infection to patients. Patients and visitors must be educated to identify the signs of infection and to adhere to hand hygiene in order to reduce risks of nosocomial infections.

Suggested activities for students Activity 13.1 • Identify the possible causes of infection. • Explain the five moments of hand hygiene, and present the possible problems related to them. • Design a protocol for hand washing in your unit for staff, patients and visitors.

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chapter

14

Communicating and teaching

Learning objectives On completion of this chapter, the student should be able to do the following: • Communicate and teach within an effective nurse–patient relationship and in such a way as to obtain the desired response from the patient. • Demonstrate sensitivity and respect in all communications with the patient, his or her family and/or significant others. • Develop effective relationships with patients and their families and significant others. • Conduct an interview with the patient in order to obtain relevant health information. • Discuss the progress of the patient in an appropriate, honest and sensitive manner. • Assess the health educational needs of the patient and community. • Give health information and/or health education to individual patients and small groups in an effective and appropriate manner.

Key concepts and terminology Communication: A process whereby information is transmitted between people. Health education: Teaching and educating patients with the purpose of improving their health, preventing ill-health or enabling them to participate meaningfully in managing chronic illness and maintaining an optimum state of wellness. Patient autonomy: The ability of the patient to manage his or her own healthcare, and participate in health discussions relating to the community in which he or she lives. Teaching: An interpersonal process involving communication with a specific goal in mind.

Prerequisite knowledge The nurse should have knowledge of the following: • A basic understanding of the professional and legal framework of nursing in South Africa • A basic understanding of the ethical framework of nursing • An understanding of the bio-psychosocial needs of the patient • An understanding of the importance of religious beliefs and cultural background relating to the giving of health information to patients.

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Medico-legal considerations • Education and health information are needs that the nurse must meet in line with the Constitution of the country. • The accuracy and effectiveness of patient education is particularly important in situations where the patient will be expected to manage some aspects of his or her treatment independently. In such a situation, incorrect healthcare teaching may lead to treatment errors as well as complications arising from them. A good example of this is diabetes mellitus: patients suffering from this disease will be expected to manage their own treatment and diet, and to monitor their blood sugar levels at home. Effective health education is thus crucial for diabetic patients if they are to be successful in controlling their condition. • Health education and the giving of health information is part of the nurse’s role, and patients’ needs in this regard must be assessed along with their other health needs. It is not necessary for the nurse to wait for health education to be prescribed by the doctor, although the doctor may be better able to explain some aspects, and some patients may also feel more reassured if they are able to speak to the doctor. • The obligation of the nurse to provide relevant health information and education to the patient is supported by legislation and a number of health policy documents: –– Patient autonomy is facilitated through education, and patients are thus enabled to manage their own healthcare and participate in health discussions relating to the community in which they live. –– Knowledge promotes co-operation and compliance on the part of the patient. –– The Patients’ Bill of Rights includes the rights to information, informed choice and informed consent. –– Failure to provide adequate information and health education may be seen as negligence, or it may be interpreted as discrimination. • The accountability of the nurse also applies to health education in that the nurse can be held answerable for what has been taught (or not taught) to the patient. If, for example, the development of post-operative complications in a poorly controlled diabetic can be traced back to inadequate health teaching, the healthcare professionals responsible for the preparation and health teaching of that patient can be held liable.

Key ethical considerations • The patient has a right to health information, and this right is enshrined in the South African Constitution. This places an ethical obligation on the nurse to provide patients with relevant health education and information. • Patients’ rights also place an obligation on nurses and other healthcare professionals to be open and transparent in all matters relating to the care of the patient. In order to maintain openness and transparency, good communication is essential. • According to the concept of patients’ rights, patients should have access to their medical records. Health professionals should therefore ensure that patients’ records are accurate and complete, and that they do not contain ambiguous, confusing or insensitive statements. ➙

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• Confidentiality of patient records must be maintained and only the patient and bona fide health professionals concerned with the management of the patient’s health problem are allowed access to them. • The ethical principles of patient autonomy, veracity (or truth telling), beneficence (doing good) and non-maleficence (doing no harm) require the giving of accurate health information to the patient.

Essential health literacy Teaching is seen as an essential part of nursing practice, in respect of both well and ill patients, with the aim of increasing their knowledge on health matters so that they are better able to manage and maintain their own health. The nurse is also the co-ordinator of patient education and acts as an advocate to ensure consistency of care. A variety of factors impact on health education: • The emphasis on primary healthcare and the prevention of ill health is important – both primary healthcare and preventative strategies are based on effective health education. • The concept of managed healthcare places a great deal of emphasis and reliance on patient autonomy. In order to render the patient autonomous, health education is essential. • The importance of health education is also based on the recognition that the aetiology of many diseases, especially chronic ones, is lifestyle based. Prevention through education for changes in lifestyle thus plays a major role in management. • Teaching is also an interpersonal process involving communication with a specific goal in mind, and effective teaching is based on good communication.

Introduction Nursing, as well as teaching, is an interpersonal activity based on communication skills. Nurses’ day-to-day work consists of a series of interpersonal interactions, and their success in helping others depends on their ability to interact with them in a positive way.

Principles of communication Communication is a process whereby information is transmitted between people. Communication may be on a one-on-one or group basis. Communication involves the transmission and reception of information between people. Usually, transmission and reception occur simultaneously during the course of the communication. Interpersonal communication is an opportunity to influence others, which is why communication is so important in nursing where the nurse strives to promote healthy living and healthy behaviours (see Chapter 15). For teaching and health education to be effective, it is important that all aspects of the communication context be taken into account. For example: • While giving health information to a patient, the nurse should ensure physical comfort in an environment that is quiet and conducive to listening. 244

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• The nurse should also be aware of the social context of communication. For example, it may be considered inappropriate, even offensive, for an unmarried person who is younger than the patient to discuss matters relating to sexuality with the patient, especially if the nurse is a member of the opposite sex. • Communication that takes place in an atmosphere of anxiety is unlikely to be effective, and so it is important to reassure the patient and ensure that the patient feels at ease before embarking upon any substantive communication. • It is not a good idea to start communication on matters requiring a great deal of time and attention on the part of the patient at a time when a lot of other activities involving the patient are taking place. • Culture must always be taken into consideration and it is important for the nurse to be aware of the patient’s cultural beliefs when engaging in communication with the patient.

Communication in healthcare settings Effective interpersonal communication plays a vital role in the promotion of health, and success at health maintenance, prevention of ill health and promotion of wellness all depend on: • effective interpersonal interactions in a variety of healthcare settings and environments • the ability to initiate, develop and maintain effective healthcare relationships • the ability to use communication skills to resolve conflicts between healthcare providers and patients and to solve communication problems related to health and healthcare.

Functions of health communication • Diagnosis: This involves obtaining information, interpreting and analysing the information, and identifying and solving problems. • Gaining co-operation: This involves relationship building in order to obtain compliance and consent from the patient. • Counselling: This refers to the therapeutic nature of the nurse–patient relationship. While in-depth counselling requires special training and skills, all healthcare workers provide comfort and support as well as empathic listening to their patients. • Education: This involves the nurse in the provision of health information to patients, as well as helping patients to achieve autonomy in the ongoing management of their health condition. Key features of health communication • Health communication should be characterised by interpersonal sensitivity and caring. Courtesy and respect are of the utmost importance, as is listening to what the patient has to say, and what the patient’s issues and fears are. If the nurse is able to demonstrate sensitivity, caring and respect towards the patient, a relationship of trust is built up within which effective health communication can take place. • Non-verbal cues that indicate positive regard and an interest in the patient, such as touching the hand or arm, focusing the gaze on the patient, and nodding at intervals as the patient talks, all tend to enhance the development of a relationship of trust. 245

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• The information that is being communicated should be clear and specific. It is important to build an open and trusting relationship in order to overcome fears related to talking about health matters. The nurse must bear in mind that many patients find talking about health matters very stressful. It is also important to find the right words, particularly if the conversation involves delicate issues such as sexuality. In addition, some health-related issues, for example those involving lifestyle changes or discussion of incurable or potentially fatal illness, are anxiety provoking for both nurse and patient, resulting in unsatisfying and ineffective communication. All health workers, particularly nurses who are in 24-hour contact with the patient, need to cultivate the ability to discuss health matters clearly and honestly with the patient, avoiding jargon and fancy terms, as these only tend to confuse the patient. • Communicating bad news or even potentially bad news is a frequent stumbling block in health communication. Indeed, many health professionals, including medical practitioners, avoid this type of discussion entirely, leaving the patient, family or friends totally in the dark. Examples of this type of discussion include telling patients, or patients’ families, that they have an incurable, chronic or even potentially fatal condition. Health professionals also find it difficult to discuss a patient’s prognosis with the family, especially if the patient is not expected to recover. There is no single right way to deal with difficult conversations like these. However, if the nurse is able to discuss death, chronicity or disability with sensitivity and honesty, he or she can help to bring closure and a degree of comfort to distressed patients and their families. The following suggestions are based on the author’s experience, but every nurse should endeavour to find ways to talk to patients and relatives about difficult or even taboo topics: –– Never minimise the seriousness of the problem, as this will only make the patient and the family suspicious. It is important that the true situation be understood in order for the patient and family to begin working through the issue. However, do not dwell on unpleasant details that may cause distress and anxiety. Phrases such as: ‘He is extremely ill and may not recover’ or ‘Her condition is very poor and anything can happen’ are often enough, but the nurse should be prepared for questions. Remember that people will usually not ask about what they do not want to know; if they do want to know, they will be persistent in trying to get answers, so being upfront from the outset saves time and trouble, and creates an atmosphere of honesty and trust. –– Never destroy hope, but rather try to promote a realistic understanding of the situation. However, if it is obvious that there is no hope and the patient is indeed dying, do not hide the truth of the situation if asked a direct question, but rather inform the family that they should prepare themselves for the eventuality of death. In this situation, a statement such as: ‘No, he [or she] is seriously ill and probably will not recover, but we are doing all that we can’ may be useful. In this way, the reality of the situation is stated while emphasising the fact that all possible care is being given. –– Always promote confidence in the healthcare team, particularly the medical practitioner. –– Answer any questions as honestly as possible and offer to arrange a discussion with the patient’s medical practitioner if desired. 246

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• Patients and healthcare professionals frequently stereotype one another; for example, patients may think that all doctors and nurses are like those seen on popular television programmes. These misconceptions must be removed if health communication is to be effective. Patients often expect health professionals to be all-knowing miracle workers, while on the other hand healthcare professionals frequently stereotype patients or underestimate their intelligence based on their age, gender, or physical appearance; for example, patients who are deaf or hard of hearing are often assumed to be intellectually incompetent. Preconceived ideas on the part of the patient may also hamper communication; for example, any lump is automatically assumed to be malignant. All such stereotypes and preconceived ideas need to be dealt with openly and realistically before effective communication can take place.

Therapeutic relationships Effective health communication occurs within the context of a therapeutic relationship. Empathy, trust, honesty, mutual acceptance, respect, caring, while retaining the appropriate social context and objectivity, are characteristic of such relationships.

Patient teaching • Learning is a process whereby knowledge and skills are gained. This can be seen in a change in attitude, behaviour, or the use of a new skill. • Teaching involves helping the individual to learn and to relate what he or she has learnt through real-life experience; knowledge that cannot be used in everyday life is perceived as useless, particularly by adults, and is soon lost. • The education of the patient, including the giving of health information, is one of the professional obligations of the nurse. • The nurse is an ideal educator for the patient as it is the nurse who has the most sustained contact with the patient, whereas contact with other health professionals tends to be more sporadic. In a hospital situation, nurses are in contact with the patient for 24 hours a day, and in a community or clinic setting, the nurse is the member of the health team who will see the patient first and who is most available to the patient.

Principles of teaching Planning

Effective teaching requires a great deal of thought and planning on the part of the teacher. It is not enough to simply throw information at patients and expect them to apply it in their own lives. The following are some of the major aspects that need to be analysed and taken into account when teaching patients: • It is necessary to determine exactly who the patients will be – whether one individual, a small group such as the patient’s family or a larger group of community members – as the whole style and pace of the teaching session will change according to the patients and the size of the group. The age of the group is also important. Teaching children is not the same as teaching adults, and teaching methods will have to be adapted according to the age of the group. 247

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• The nurse must also determine exactly what needs to be presented, at what level and in what kind of detail. It may be helpful to establish this by asking the patient what he or she would like to know and in what kind of detail. However, healthcare priorities also need to be taken into account: the patient with TB may say that he or she just wants to know about the frequency of clinic visits, yet there are several major aspects that need to be discussed with the patient if management is to be successful. It is also advisable to consult with the multidisciplinary team concerning the teaching of patients. Standard teaching protocols or programmes should be developed with the participation of the entire multidisciplinary team. Similarly, community health-education programmes require not only consultation with the multidisciplinary team, but the full participation and approval of the community as well. • Successful teaching requires an environment that is conducive to teaching and learning, and health teaching is no exception. It is important to establish an environment and an atmosphere in which the patient can feel comfortable, especially if anything of a sensitive or confidential nature is likely to be part of the discussion. The patient’s anxiety levels may preclude learning initially, and these fears may need to be allayed first before embarking upon any actual teaching. • The nurse must assess the patient’s readiness to learn. Timing is important. The current health status of the patient will also impact on his or her readiness to learn. Many patients are in a state of denial about their health problem, especially in the early stages of coping with a serious and/or chronic illness. It may be better to delay the teaching until the patient can work through the stage of denial, and the nurse should first help the patient to become aware of reality before proceeding with specific teaching. Patients who are acutely ill tend to have all of their attention focused on their immediate needs and the demands of the illness, and are not in a receptive state as far as patient education is concerned. Such patients are better left until recovery has begun and they can think ahead, although the nurse can gently introduce key educational aspects during the acute phase of illness as and when they ask questions. Leave some written materials with the required information with such patients or the family to strengthen the verbal information provided if they can read. • It is also necessary to assess the cognitive and intellectual level of the patient so that health information can be presented in such a way that the patient will understand it. Language and comprehension ability are also important, and sometimes it is necessary for the nurse to use an interpreter to get the message across and have it understood by the patient. Teaching methods

Teaching involves helping patients to learn and to relate what they have learnt to reallife experience. Because people learn in different ways, the nurse should know how to use a variety of teaching methods appropriately. The selection of teaching methods (see Table 14.1) will depend on the age and level of understanding of the patients, as well as on their education, literacy level and intellectual capability. The use of well-selected audio-visual media can also enhance and facilitate learning. Audio-visual aids, such as charts, overhead transparencies, slides, videos, posters and films, must be selected 248

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according to the topic and the teaching methods, and are used to make the teaching– learning session more interesting. Table 14.1  Teaching methods Formal lecture

• This is a useful method for giving information to large or mediumsized groups. Lectures can be prepared in advance, a schedule can be put up and, if desired, specialists can give some lectures. The teaching material is prepared beforehand and is presented formally. The use of visual aids can help to make a lecture more lively and interesting. The lecture is a cost-effective method of giving information and can be given in a variety of settings. For greater effectiveness, the lecture can be combined with other methods, such as a demonstration. Ideally the teacher should aim to involve the group as much as possible and to deal with individual differences. If there is interaction between teacher and students during the lecture, anything not understood can be repeated and explained, depending on the needs of the students. • The lecture does have some disadvantages, however. The retention rate is low (20%), and a formal lecture does not necessarily enhance problem solving. In a lecture, the students are passive unless they ask questions. Fast learners may become bored, while slow learners may battle to keep up with the pace. A formal lecture may not be relevant to the life situations of the students; however, the teacher can minimise this if he or she knows the group. • The teacher may not know if the lecture has been understood unless he or she asks questions, and there is not always enough time for this in a formal lecture set-up. • The lecture is a useful method for presenting basic principles, or for introducing a topic, but for in-depth learning follow-up, the use of other methods is essential.

Demonstration

• A demonstration involves showing students how something is done. The demonstration is a useful way to teach skills and integrated knowledge. The teacher shows the procedure or skill. This is followed by discussion and questions. Ideally all of the students should then have an opportunity to practise the procedure or skill, and therefore groups for demonstrations should not be too large (no more than six). In health teaching, it is often very useful to do a demonstration in the patient’s own home, using the patient’s own equipment or household items. • Students at a demonstration should see the teacher as an expert in that particular skill or procedure, and so it is important for the teacher to ensure that he or she is demonstrating correctly: the teacher must be a role model for the students. The teacher should practise beforehand to identify and solve any problems. During the teaching/learning session, the students will require constant encouragement, especially if it is a difficult or complex skill. ➙

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• Disadvantages include the amount of time required for preparation and setting up. Equipment is sometimes not available or it may be costly, especially if disposable items are being used. The demonstration is unsuitable for groups of more than six persons. Space is required for demonstrations, especially if students are to practise what they have been taught. Group discussion

• A group discussion involves 3–15 students in a discussion of issues and joint problem solving. • Working in groups can be useful to clarify facts, share experiences, solve common problems and give mutual support. Patients who have a common health problem often form a support group, which serves as a support system as well as a means of sharing of information. • Different types of group discussion can be identified according to the purpose of the group: –– Brainstorming groups are formed for solving problems. –– Buzz groups are formed from a larger group – they focus on specific aspects of the main discussion and then report back to the larger group. –– Role-play groups are formed in order to act out a scenario. –– Therapy groups, such as encounter groups and psychotherapy groups, are ongoing groups that deal with relationships and feelings, and provide support to members in the group. • It is important to note that the leadership qualities of the teacher are crucial for successful small-group work. Small groups have their own dynamics, and if the leadership role moves away from the teacher, the purpose and direction of the group may be altered. • Disadvantages of group discussion include the fact that this is a time-consuming method of teaching. Some groups indulge in a great deal of talk, but no action is forthcoming. It is also possible for a group to be dominated by one or two strong-minded individuals who intimidate shyer individuals and may suppress minority viewpoints. Once again, good leadership on the part of the teacher is the solution to this problem.

Role play

• This is a method used for small groups, in which a situation or issue that is pertinent to the group’s circumstances is first acted out and then discussed. • The participants themselves, with some of the group acting as observers, may do the acting out. Alternatively, the teacher and helpers may act out the scenario, or visual aids such as puppets can be used for this. • Role play requires a fair amount of preparation. The role play needs to be scripted, and the scenario(s) should be well thought out. The script should sketch the scene and the role rather than setting out specific dialogue – the players have the freedom to interpret the role. Each player has his or her own script and only the teacher has the entire scenario and script: ➙

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–– Players should be briefed before commencing the role play. –– An icebreaking session may be necessary in order to get the participants to relax. –– Debriefing is needed once the role play is over to indicate that the players are themselves once again. –– The final step is discussion of the role play. • The disadvantages are, once again, the time needed for preparation, acting out and discussion. In addition, some players may become upset by the role that they are required to play, and this requires careful handling on the part of the teacher. Other teaching strategies

The following are other methods that can be used in health teaching: • Various well-known everyday games can be adapted and used in teaching. Games are especially useful for teaching terminology and for giving health information to children. The effectiveness of games depends on the patients’ familiarity with the game, as well as on literacy levels. Games are the sort of thing that can be used to keep patients amused while waiting for consultation, but still get across an educational message. • Simulation activities allow patients and health professionals to participate in or rehearse aspects of reality related to the rendering of healthcare, such as disaster practices or the simulation of cardiopulmonary resuscitation techniques using dolls. Simulation can be used to practise skills or reactions to situations; team responses can also be rehearsed. Following the simulation exercise, discussion takes place to identify problems and develop solutions. However, it must be remembered that simulation only imitates reality; reality is always different and unpredictable, but simulation can give individuals confidence in skills and in the application of protocols and guidelines. • Case histories and case studies may be useful to illustrate to patients certain aspects of self-care or various ways in which others have overcome problems. These methods are mainly used for the teaching of other health professionals. • Information packages can be used to give patients information in written form. This method may be useful if patients will need to take in a lot of information or refer to information frequently. Examples include booklets on diabetes mellitus, TB or HIV/AIDS. Such booklets can be as simple or as technical as required, and are often used as handouts to reinforce other methods of teaching. • Analysis of patient records affords valuable opportunities for teaching and learning.

Evaluation Evaluation is an important component of health teaching. The best evidence of the success of health teaching in the patient is evidence of effective self-care, as well as changes in health behaviour, such as stopping smoking, compliance with TB treatment, or improved infant nutrition. It may also be possible to back up some of 251

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these parameters with objective clinical tests. For example, elevated carbon monoxide levels in the blood indicate that the patient is still smoking, no matter what he or she tells the nurse. It may also be possible to measure changes in functional health status as an indication of effective self-care. Examples include blood glucose control in the diabetic patient, improved exercise tolerance in the patient with chronic pulmonary disease, and satisfactory growth and weight gain in previously malnourished infants. Methods used for evaluation include the following: • Direct observation • Physical assessment of the patient, as well as selected diagnostic tests • Questionnaires given to patients • Interviewing patients often, combined with home visits to see how the patient is coping in his or her own circumstances • Review of patient records to evaluate progress over time.

Record keeping Record keeping in relation to patient teaching and health education is an important component of the nurse’s legal responsibilities. Good records also assist other health professionals who may be involved in the care of the patient. The nurse should record the following: • The content of all teaching sessions and the teaching strategy used, including the date and time of each session • The response of the patient or group of patients • The results of any evaluations, such as demonstrating to the nurse how to give an insulin injection or do a blood glucose test in the case of a diabetic patient • Further planned educational activities.

Conclusion Communication is an aspect inherent to teaching, and communication with the patient, family and significant other cannot be emphasised more. In a healthcare setting, this needs to be continuous and consistent. Messages of health promotion need to be repeated constantly to ensure that patients and their families understand them. Behaviour change is seen as a measure of the impact of successful communication.

Suggested activities for students Activity 14.1 Working in groups, develop two posters for the following: 1. To effectively communicate the ill effects of smoking for an individual and for a group ➙

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2. To effectively communicate the nature of sexually transmitted diseases, their causes and prevention. • The posters should convey a clear message while taking into account the culture and background of the target group. • Presentation of the posters should be followed by an oral presentation.

Activity 14.2 Work out a short educational presentation on a topic of your choice to be given to a group as well as to an individual patient. Specify the most suitable teaching method for both the group and the one-to-one situation, and give a rationale for your choice of method.

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Learning objectives On completion of this chapter, the student should be able to do the following: • Discuss the skills and attributes that are required to develop a satisfying career in nursing. • Participate meaningfully in the development of the profession, and make an effective contribution to the rendering of health services in the community. • Project a professional image that will inspire respect, appreciation and esteem in others. • Discuss the relevance of being a member of and participating in the activities of organisations that aim to enhance the wellbeing of nurses and improve the quality of nursing service. • Take an interest in political developments and legislation that may impact on nursing, and be in a position to give appropriate input and comment. • Be familiar with current labour legislation and the way in which this impacts on the nursing profession. • Apply adequate mechanisms within the clinical situation for dealing with problems and grievances in an appropriate manner, and make proper use of these mechanisms. • Participate in the development of job descriptions, and grievance and disciplinary procedures that are essential in order to ensure that problems are dealt with effectively.

Key concepts and terminology Moonlighting: Working shifts at an additional job in another institution other than a full-time position at one’s primary employment. These shifts are usually worked through a nursing agency.

Prerequisite knowledge The nurse should have knowledge of the following • An understanding of the role of legislation, morals and values in the healthcare sector.

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Medico-legal considerations • Nurses must be familiar with relevant labour legislation and ensure that their clinical practice falls within the applicable legal parameters. • Nurses should ensure that they are familiar with the applicable scope of practice regulations so that they know what is expected of that level of practitioner, and to avoid being exploited outside of their specific scope. • Any disregard of the rights of the nurse, whether these rights are professional rights or rights arising out of labour legislation, may expose supervisors and employers to legal action via the labour court.

Key ethical considerations • Nurses should be careful to be professional, correct and supportive in their dealings with their fellow nurses. • Accidents and unintentional harm to patients can occur, and thorough analyses of such incidents should be seen as learning experiences in order to avoid future incidents. • On the other hand, instances of deliberate negligence, malpractice and maltreatment of patients are not acceptable and should be reported with a view to taking action through the appropriate channels. • Nurses’ rights are important but must be offset against the rights of the patient and the ethical and professional norms of nursing. Participation in any industrial action does not absolve the nurse from any charge of negligence that may be brought as a result of such action. • Although moonlighting and overtime are almost universal among nurses, they must ensure that they do not become so tired as to be unable to render expected services to their employer. • Nurses must also care for themselves by taking timely and appropriate action to deal with problems. It is unethical and unfair to colleagues if individuals allow such problems to develop to the extent that they cannot function effectively.

‘…in the right atmosphere, people will contribute and make commitments because they want to learn, to do good work for its own sake, and to be recognized as people ...’ (Senge 2004: 200)

Essential health literacy The nurse should have an understanding of patient rights and the Batho Pele principles in the execution of patient care.

Introduction This chapter considers the needs of the nurse, and how they can be met. It looks at the roles of the nurse, the community, other members of the team, the employer, unions, 255

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legislation and the media. The aim of the chapter is to empower nurses to enable them to do their job while getting maximum satisfaction, enhancing the image of the profession and meeting the needs of the community. What does a nurse need? One may as well ask: ‘How long is a piece of string?’, unless the question is put into the perspectives of: • achieving job satisfaction, which includes being empowered to practice • giving quality service in terms of making a positive difference • leading a balanced life. The above three perspectives should encompass the needs of almost every person. After all, we spend almost one third of our lives working. Many would argue that the needs of the nurse and the needs of patients are on opposite ends of a continuum, if not actually mutually exclusive, and that there must be inherent conflict in trying to satisfy both sets of needs. This chapter will show that this is not the case and that, in fact, meeting the needs of the nurse will inevitably lead to meeting the needs of patients. The needs of the nurse are discussed below under four main headings: • The need for an identity • The need for recognition • The need for support • The need for protection.

The need for an identity This need can be further subdivided into two areas, namely the need for a personal identity and the need for a collective identity.

The need for a personal identity A student entering the nursing profession often encounters the real dramas of life for the first time, head-on and in rapid succession: the joy of birth; the sadness and loss of death; the tragedy and pain of illness, disability and deformity; the satisfaction of seeing patients get well again; the controversial questions of abortion, euthanasia and suicide; and the horror of rape, murder and abuse – to name but a few. The nurse is expected to be mature and emotionally strong, to comfort others, to put aside his or her own feelings, to empathise, and to be ‘normal’ at the end of the day. Nurses can only do this if they have, or are helped to develop, a strong personal identity to know who they are, what they want from life, what their good and not-sogood points are, and what their own feelings are about issues. In order to clarify individual values in the context of the nursing profession, it is worthwhile taking time to ponder the following questions • Why did I become a nurse? • What does it mean to be a nurse and to nurse someone? • What are my strong characteristics? • What are my weak points? • How do I feel about: –– death? 256

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–– –– –– –– –– –– ––

• • • •

suicide? abortion? euthanasia? mental illness? people living with HIV/AIDS? contracting HIV/AIDS or other diseases at work? nursing people with beliefs, cultures, colour and sexual orientations differing from mine? What coping skills do I need to develop? What and who can help me develop these skills? What demands will nursing place on my life and me? Can I cope with these demands? Do I want to fit them into my life?

Deep introspection about critical issues is essential for nurses to develop their own value systems and to measure these against the community value system. In developing their own strong and positive personal identities, with the sense of acceptance and security that goes with that, nurses will develop a sense of pride, not only in themselves but also in what they can offer to patients and colleagues. Nurses need, ultimately, to integrate this newfound identity into their total life, and balance this harmoniously with all the other aspects of their identity as members of a community, as companions, friends, husbands, wives, lovers, mothers, fathers, and so on.

The need for a collective identity The nursing profession needs to maintain an identity with which each nurse can feel comfortable and by which the community can recognise and judge the members of the profession. This collective identity must be one that is developed by the members of the profession and which then serves as a set of guiding principles on which they can mould their professional life. This professional identity must be: • realistic (even though it may be based on idealistic goals), in order that nurses can buy into it and live by it • relevant to the needs of the community. It should therefore be adapted from time to time so that it does not become obsolete in the eyes of society. For example, the profession’s collective identity should be one that is very cautious about taking sides on contentious issues such as abortion. It should continuously strive to recognise the rights of individuals to make choices. In essence, therefore, while a nurse has a need to belong and to be guided by collective policy about nursing matters, the profession as a whole needs to review its stand on matters regularly, if the profession is to remain in step with and be relevant to society’s needs and values. Buresh and Gordon (2006: 27) state: ‘An accurate picture of nursing will emerge only when nurses and their organisations tell journalists not who nurses are and how virtuous they can be, but what they do and why it is so important’ (emphasis added). Professional organisation of nurses remains an important strategy to develop and strengthen a collective professional identity.

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The need for recognition Nurses have a need for recognition, which takes several forms: • Social recognition – of self and of the collective rights of nurses • Financial recognition • Other recognition as an employee from the employer • Recognition of nurses’ rights • Inter-professional recognition.

Social recognition The individual nurse needs recognition from society as a whole, as well as from his or her peers for the individual contribution that the nurse can make or is making to meet the health needs of the community. On the other hand, the nursing profession as a whole needs recognition from society for the contribution it makes to the health and welfare of the community. Needless to say, in order for this need to be met, and for society to recognise nursing as essential to its existence, nursing must be seen by society to have value. Nursing therefore has a reciprocal responsibility to care for society and to portray to society its indispensability. Nursing will not receive the necessary recognition if society believes it can do without nurses, or can replace them, or if the image society has of nurses is generally unfavourable. Recognition by society can take many forms, as discussed below. If the community shows appreciation, even if it is just by saying ‘thank you’, the job satisfaction of nurses will be greatly enhanced. Nurses need to know that their intervention has been recognised, is relevant and is making a positive difference to the community in which they live. Financial recognition Nurses have a need to be, and to feel, adequately remunerated for the services they render to the community. The length of training and the physical and psychological commitment that go into nursing care are generally under-recognised throughout the world in terms of compensation. Unfortunately, employers tend to see nurses as an expense (and nursing services usually make up at least 50% of hospital expenses), rather than as generators of income, particularly in the private sector. If it were not for the need for nursing care, patients simply would not be admitted to hospital – they could go straight home after surgery, for example! There is a need for the employer to give financial recognition for performance and loyalty so as to encourage nurses to give of their best, and systems need to be developed to measure the quality an employer can expect in return for this investment. More about fair remuneration practices can be found later in this chapter. Other recognition from the employer Nurses are, or should be, proud of their work and the effort they put into rendering quality nursing care. Apart from financial or material recognition, nurses have a need for positive feedback as well as constructive criticism from their employers. So often the cry is heard: ‘Why do I only hear from the boss when I’ve done something wrong? A word of praise or encouragement when I do things right would go a long way.’ Nurses are generally very creative and practical, and have a great deal of common sense. By including all levels of nurses in participative decision making regarding all 258

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aspects of nursing care, the management of the organisation can, probably without exception, improve the quality of the service being offered. Recognition of this contribution lends itself to better management as well as improving job satisfaction.

Need for recognition of nurses’ rights Society and the employers must recognise nurses’ rights. (These rights will be discussed later in the chapter). Nurses, as people and as professionals, have certain rights, many of which are sometimes not given the necessary recognition. This, in the past, has led to demoralisation, frustration and even anger on the part of nurses. Neither society nor the employer can demand, nor can they expect, that nurses function in an environment where their rights are infringed, or are perceived as being infringed. Inter-professional recognition There is a need for nurses to recognise and be recognised by the other members of the health team. Each member of the team has a unique and special part to play in healthcare delivery, and mutual respect and trust is essential for quality patient care. Just as nurses respect their health colleagues, so they should command respect from them, and they should not accept any disrespectful and abusive behaviour from them. Nurses need to stand collectively to put a halt to some of the rude and abusive behaviour of some health professionals towards nurses. Nurses need to work hard at developing appropriate responses and sufficient assertiveness (not aggression!) to maintain the image of the profession and to develop sound professional relationships.

The need for support Support in the workplace Nurses need support systems of various types in their working lives. The need for a mentor or role model

Nurses needs another professional person whom they respect and who has the necessary skills to assist in their professional development. This person should be able to impart knowledge, practical skills and coping mechanisms, as well as be a good example of what a nurse should be. It is in this way that the positive elements and qualities of the nursing profession can be fostered and passed on. The need for physical support systems at work

Nurses need safe, up-to-date and appropriate equipment to assist them in their tasks. They also require a safe working environment (which is a need as well as a right, and will be discussed further under the rights of nurses). They also need access to efficient patient transport and communication systems, as well as back-up support from other members of the health team and support services in order to function effectively. In the absence of specific members of the health team, nurses need to be empowered and authorised to function within an extended scope of practice in the interests of meeting patients’ needs.

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The need for support from other members of the health team

Management and other members of the health team need to support nurses in their daily activities and nurses need to feel confident that the team will stand together. Nurses have a need to rely on the support of others, not only when things are going right but also when negative incidents have occurred that were unavoidable or could have been better managed. The need for administrative support

Nurses need administrative and non-nursing support so that they can focus on nursing patients, particularly in the light of the nursing shortage. Ideally, there should be a ward secretary or personal assistant to do all the filing, manage visitors and patients when they arrive, assist with the staff duty and leave rosters, and so on. In addition, there are many non-nursing tasks undertaken by nurses that could be done more efficiently and cost effectively by appropriate persons. Examples are porters transporting patients or going to the pharmacy for urgent prescriptions, and technical staff taking care of equipment. The emphasis on evidence-based care requires nurses to have access to the best-available evidence to inform their practice. Access to computers and the Internet in the clinical situation is limited, and absent in most cases, which limits the opportunity for nurses to access such evidence. While mobile phone technology with modern smartphones allows access to the Internet, many workplaces do not allow the use of mobile phones at work. The need for support from professional colleagues inside and outside the workplace

Nurses need to create their own collegial support systems, both inside and outside the workplace. This can be done inside the workplace by forming committees and support groups to address various issues, such as the following: • Salaries and conditions of service • Quality of care and best practice • Ethical issues • Review of negative incidents to learn from errors • Debriefing following difficult or emotional incidents, for example counselling • Conflict management. These and other issues should also be discussed in a wider context outside the workplace. This helps to maintain objectivity and to gain new insights and expertise. Nurses usually elect to do this by joining organisations consisting of nurses, such as nursing organisations or professional societies, or by joining a multidisciplinary organisation that has a nursing component. These structures should be fully utilised by nurses as support systems and as sounding boards. Nurses should also access journal articles as there is a large variety of open-source scientific nursing journals available that do not require a subscription.

Personal support systems Apart from the support systems needed by nurses to assist them in their professional capacity, they need to balance their lives through other support systems as well.

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The need for a balanced home life

Nurses need to be able to leave the complexities of nursing at work and to go home to a less stressful, safe, contented and supportive system. Whether this entails going home to immediate family, friends or pets, or to a house, a flat or a room, nurses need a distraction from their emotional and physical work life. A nurse needs to work hard at relaxing! As strange as this may sound, nurses tend never to be ‘off duty’ and need to learn to switch off to create quality leisure time. Even though nurses’ work is physically active, they must try to take some form of exercise for relaxation and to keep fit. Nurses also need to develop healthy eating habits to keep well and to maintain adequate energy levels, remembering that most nurses are on their feet all day. If nurses are having difficulty coping with the stress of work and this has a negative impact on their lives, they should seek assistance in managing that stress. Sometimes offloading on friends, colleagues and family is not enough and professional assistance becomes essential. As nurses become the victims of the stress in their effort to meet the often overwhelming needs of patients and their families in clinical practice, they can develop compassion fatigue. Multiple symptoms are experienced, including workrelated symptoms (dread of going to work, absenteeism), physical symptoms (diarrhoea, headache, fatigue, sleep disturbances, cardiac symptoms) and emotional symptoms (substance abuse, mood swings, depression). This not only affects the nurse’s job satisfaction, and emotional and physical health, but it also decreases productivity in the workplace and increases staff turnover if not addressed proactively and constructively. Compassion fatigue will obviously also impact family and loved ones. However, the nurse has a responsibility to recognise this and deal with it proactively by seeking assistance from a supervisor or colleague, or a healthcare practitioner.

The need for protection Nurses, individually and collectively as a profession, need protection. They need protection to be able to exercise their rights and to be able to influence politicians and other decision makers to improve care, and they need legal protection.

The rights of the nurse that require protection The rights of all South Africans, enshrined in the Bill of Rights in Chapter 2 of the Constitution of the Republic of South Africa (1996) will not be specifically discussed here but are clearly applicable to nurses as well. Readers are referred to the Constitution for details on such rights as privacy and confidentiality. Below is a list of some of the rights important to nurses. Readers are also referred to the South African Nursing Council website (http://www.sanc.org.za), where the Council acknowledges that nurses have rights, some of which are addressed below. It is worth noting that the Council endorses 14 specific rights in addition to those enshrined in the Constitution of the country, as well as labour legislation, ‘provided that the exercising of such rights does not put at risk the life or health of patients’. The right to practise

Once registered with the regulating body (South African Nursing Council) and until such time as that registration is withdrawn by that Council or voluntarily surrendered, a nurse has the right to practise his or her profession. It is obviously important and a 261

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legal requirement in South Africa to maintain this registration to continue practising, and in future this requirement will be linked to undertaking compulsory continuous professional development. The corollary to this is, of course, that a person who is not registered does not have a right to practise as a nurse. This is important as it affords protection to nurses. This right to practise does not mean that a nurse can demand to be employed by any specific employer. However, nurses do have the right to seek employment and to be employed, or even to be self-employed in the case of professional nurses and midwives, and to practise their profession within the specific scope of practice laid down by the Council. The Nursing Act 33 of 2005, together with its regulations, governs the scope of practice. The right to practise independently

The right to practise independently is a right granted to professional nurses. This means that the nurse may carry out nursing tasks and procedures without requiring authority or prescription from anyone else (eg as a private nurse practitioner). It also means that the nurse may take charge and be responsible for a nursing care plan for his or her patients within the scope of practice regulations laid down by the Council. Clearly, if the nurse is employed in a health service institution setting and is not the nurse in charge of the nursing team, he or she may be expected to take delegated instructions from another nurse, or from a doctor or dentist, even though he or she remains responsible for the execution of such instructions. The important aspects of this right to practise independently are as follows: • A professional nurse is a recognised professional in his or her own right and can practise independently. • Even if the nurse takes instructions from another registered nurse, doctor or dentist, he or she is still accountable for his or her own actions and cannot plead merely having ‘done as I was told’. The right to be empowered to practise

A nurse who is employed has the right to be enabled to practise through the provision, by the employer, of suitable and safe equipment and other support systems (as mentioned above). It is important to note that, should such equipment and/or a safe working environment not be available to the nurse, this should be recorded and brought to the attention of the nurse’s seniors. Because the nurse has the right to be empowered in this way to practise, his or her seniors will have to take responsibility for any problems arising due to lack of equipment and/or an unsafe working environment, provided the nurse could be seen to have attempted to entrench his or her right and to attempt to rectify the problem. The right to a fair remuneration package

A nurse has the right not to be exploited and to be remunerated fairly for his or her contribution to the care that is provided. This remuneration package should reflect the nurse’s performance and loyalty to the employer, as well as take cognisance of the nurse’s attempt to develop professionally. This right is clearly affected by supply and demand, and the ability of the nurse to negotiate a good deal for him- or herself. This 262

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is one area where the bargaining power of nurses organised together is imperative and advantageous. Nurses who stand together and bargain collectively for fair remuneration are usually more successful than individuals at achieving higher salaries. Performance-based pay is becoming recognised as a recruitment and retention tool for good performers. Remuneration based on salary scales with notches being granted merely for number of years’ service without a fair performance evaluation can lead to mediocrity in long-serving staff and frustration for high-performing competent staff. The right to fair benefits

Nurses as employees have rights to certain fair employment benefits, some of which are entrenched in law and some of which form part of collective negotiations. At present in South Africa, different Acts govern the various employment sectors. For example, in the private sector, the Basic Conditions of Employment Act 75 of 1997 (the BCEA) sets down minimum requirements for employment in the private sector (eg number of days’ annual leave, sick leave, overtime, etc). In the public sector, benefits are laid down by the Public Service Act and the Public Service Staff Code, and in collective agreements between employers and employees. Recent agreements in the public sector standardise minimum requirements in terms of issues such as leave, sick leave, length of shifts, overtime, maternity leave, compassionate leave and childcare leave. The right to fair employment practices

The Labour Relations Act 66 of 1995 (the LRA), and its amendments and regulations, grants employees, including nurses, the right to fair labour practices. This means that nurses have the following rights, among others: • The right to a fair disciplinary procedure in the event of a complaint against them. Each employer’s disciplinary procedure should clearly spell out at least the employee’s rights listed here. An employee involved in a disciplinary hearing has the right: –– to be given timely notice of the charge against him or her –– to be notified of the charge in writing –– to representation –– to call witnesses –– to cross-question management’s witnesses –– to a translator if required –– to a neutral chairperson –– to be advised of the outcome in writing –– to appeal against the decision. • The right to a fair grievance procedure that assures that the nurse’s complaint will be attended to. • The right to protection against unfair discrimination on any ground, including race, gender, ethnic or social origin, sexual orientation, age, disability, religion, conscience, belief, political opinion, culture, language, marital status or family responsibility. Of particular note here is the right to conscience or conscientious objection. This provision in the LRA and other relevant Acts, together with the right to conscience in the Bill of Rights, gives the nurse the right to refuse, for example, to take part in an abortion. Should an employer insist that a nurse participate in an abortion 263

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and then dismisses that nurse for refusing, this will be regarded as discrimination in terms of the LRA as well as an infringement of the nurse’s rights in terms of the Constitution. It is imperative, however, that the nurse makes his or her conscientious objection known to the employer upfront, and preferably in writing, in order that the right is protected, and also so that alternative arrangements are made to cater for patients’ needs and rights. The right to a safe working environment

The nurse, in terms of the Occupational Health and Safety Act 85 of 1993, has the right to a safe working environment. It is the responsibility of the employer and the health and safety committees to ensure that the nurse can practise safely. Nurses need to get involved in the health and safety committees required by the Act in order to ensure that they can monitor and control the safety of the environment. The right to compensation following an injury on duty

In terms of the Compensation for Occupational Injuries and Diseases Act 130 of 1993, the nurse has a right to compensation in the event of being injured on duty or acquiring an occupational disease, for example tuberculosis (TB). This compensation includes medical costs and sick leave and, in the event of permanent disability, a lump sum or a pension, depending on the severity of the disability. Sometimes it is difficult to prove that an injury or disease was acquired while at work (eg hepatitis B infection), but the requirements are clearly laid down in the Act, and nurses should immediately seek assistance should they be of the opinion that they may have been injured or may have acquired an illness in the scope of their employment. Any needle-stick injury or possible exposure to hazards at work should be reported immediately to the employer in order that processes are put in place should compensation be inevitable. The right to strike

At present, the LRA and the Constitution entrench the right of all employees to take part in protected strikes provided certain procedures have been complied with. However, the LRA makes provision for an Essential Services Committee to declare certain services essential. Essential services are the Parliamentary Service, the South African Police Service, public health services, and any service which, if interrupted, would endanger the life, personal safety or health of the whole or any part of the population. Employees in such services may not strike, but must refer unresolved disputes (eg about pay) to arbitration. The public service health services are declared essential services, and nurses employed in the public service may not strike. The unions and the government have been negotiating a minimum service level agreement for a few years now, which will provide a framework on minimum service level agreements for services designated as essential. Until such agreement has been reached, nurses employed in the public service will not have the right to strike. At the time of going to print, such agreement had not yet been reached. Nurses employed in the private sector do have the right to strike, as these services have not been designated as essential. These services are businesses, which will not be able to deliver a service if there are no resources or staff. 264

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The right to vicarious liability

Nurses who are employees have a common-law right, in terms of the master/servant nature of the employment contract, to protection by their employers should they be sued for negligent acts arising out of the scope of their employment. This is known as vicarious liability and, in theory, means that the employer will be responsible for the payment of damages awarded to a patient by a court. However, it must also be remembered that the employer has a right of recourse to claim back from the negligent employee the amount of damages the employer had to pay, unless that right has been specifically waived. For this reason, nurses should seriously consider their own professional indemnity insurance, even though their employers can be sued in their place. For a monthly premium to an insurer, or as part of membership subscription to certain employee organisations, nurses can cover themselves against this risk. The right to adequate time off

A nurse has the right to expect to work only those hours that were agreed to in terms of his or her contract of employment. Any overtime or extra shifts worked therefore must be agreed to by both the employer and the employee, and compensated for in addition to normal pay at the rates laid down by relevant legislation, for example the Basic Conditions of Employment Act 75 of 1997. The right to time off is a very important one. Nurses need time to rest, leisure time and a balanced life, as previously discussed. The fact that many nurses work additional hours and even moonlight because they cannot make ends meet is a serious problem; it impacts on the right to time off as well as on the quality of care that can be offered due to being tired. Remuneration of nurses should be such that there is no need to work additional hours or have more than one job. Organisations representing nurses should lobby hard and negotiate better salaries for nurses to protect the right to time off. The right to ‘blow the whistle’

Any nurse who witnesses a violation of patients’ rights, or poor or unsafe practices, has a right and obligation to draw this to the attention of the relevant role players. This is known as whistle blowing, and is one right that nurses often feel intimidated about and are sometimes afraid to exercise. As stated by Trevor Clay (1987: 47), even when it is in the patient’s rather than the nurse’s interest to speak out, nurses have great difficulty in doing so for fear of victimisation. A nurse should never have to place patients’ rights and the protection of patients at risk because of a fear of victimisation and possible loss of employment. This right and obligation of the nurse to patient advocacy should be protected at all costs, and nurses need to be encouraged to speak out on their own and on patients’ issues. The right to recognition and respect

This right is actually an earned right – it is something that is fostered by delivering a quality professional service. However, it is a right nonetheless, and nurses collectively must cherish the recognition and respect granted to the profession by other health professionals and by the community. Nurses will earn this right if the service they offer remains relevant to the community – that is, that they are seen as necessary and that 265

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they make a positive difference in the lives of that community. The higher the value the community places on nurses, the higher the level of respect and recognition.

Needs of the nurse in terms of collective action Nurses need to recognise the value of standing together to improve their own position as well as to make an impact on the overall health and care of the community, which must be seen as the primary objective of nursing. As Clay (1987: 150) states, ‘if we are in step with society’s values, are organised to speak with one voice and with unity, then the power we have at our disposal is democratic power’. The need to organise

Nurses need to organise themselves at workplace level as well as at provincial, national and international levels: • At workplace level. Nurses should create a committee system in the workplace to deal with their day-to-day working lives and to participate in and influence decisions about their work. These committees should be established democratically – that is, the committee members should be elected by their colleagues (and not appointed by the nursing managers) to be truly representative of the nurses.   The committees should ensure that they are formally recognised by management as the mandated group with whom management interacts. Regular meetings between management and these committees should take place, and the committee members should give immediate feedback to all the nurses. All the nurses should also have an opportunity to meet with the committee members before management/committee meetings in order to mandate the committee.   The committee members should be given training in meeting procedure by management or by their respective nursing organisations or trade unions to allow for effective and efficient interaction between management and themselves.   The committee should also be able to link in with the representative nursing organisations or trade unions for guidance, to keep up to date with developments and to maintain channels of communication on a broader basis than just workplace level. • At provincial and national levels. There is a need for the nursing profession to organise itself at national and provincial levels for a number of reasons: –– To create a large united front and collective bargaining power base to influence decisions about nurses and nursing –– To stand united on all health and related issues to lobby for change in the interests of the communities the nurses serve –– To create a broad communication network and support system to share knowledge, developments, research and educational opportunities –– To negotiate special deals on a collective basis, for example affordable professional indemnity insurance cover and other group insurance schemes –– As a national body, to forge links internationally with other nursing and healthrelated groups to remain relevant and up to date, and to share knowledge. • At international level. Nurses and midwives have organised themselves into the International Council of Nurses (ICN), the International Confederation of Midwives

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(ICM), and Sigma Theta Tau International (STTI), as well as international specialinterest groups such as operating-theatre, infection-control and wound-care societies as well as ICN networks for advanced practice, HIV/AIDS and education. These international bodies are critical in influencing and standardising nursing care and best practice, salaries and conditions of service on a worldwide basis. The ICN works closely with the International Labour Organization (ILO) regarding the latter. The nurses in South Africa, after having been ostracised by the international network for a long time during the apartheid era, rejoined the ICN in 1997 through DENOSA (the Democratic Nursing Organisation of South Africa) to become part once again of the greater international nursing community. The need to influence health and health services

Although partly addressed above, nurses do need to positively influence health and health services on a broad basis, not only in the interests of the community, but also to enhance their own job satisfaction and the esteem of the profession. Nurses can do this collectively in a number of ways: • By the image they portray to the community. Nursing is a service profession, and the community will determine whether it needs that service or not. If the community believes the service is indispensable and if it holds the profession in high esteem, it will be prepared to recognise the profession financially and give it the respect it commands. The behaviour of each nurse as a professional at grassroots level, together with the general impression created by the profession in the eyes of the community, will either enhance or diminish the status of the profession. • By using the media effectively. Nurses must be seen to be lobbying for the health and welfare of their patients. They also need to let the community know about nurses’ needs. The media are very powerful, whether it be radio, television or the written word, and nurses must learn to use them appropriately. • By influencing the legislation relating to health and health services. There are approximately 170 000 nurses registered in South Africa, all of whom are of voting age. If nurses could stand together on issues important to them, the legislators in the country would have to listen. Nurses need to organise to ensure that they constantly lobby the political decision makers at district, regional, provincial and national level if they wish to make a difference. • By taking an active interest in the activities of the various health professional councils, most notably the South African Nursing Council. Nurses need to ensure that Council members remain relevant to the issues that need to be addressed. While these members are appointed by the Minister of Health, the profession is invited to nominate potential members – and should do so. The Council has a great influence on nursing legislation and nursing training, and the organised profession should make regular representations to it, as well as to monitor its activities. Other health professional councils, for example the Health Professions Council of South Africa, must also be monitored, and representations should be made when necessary. • By choosing the correct leaders. The impact that the nursing profession can make and the benefits it will harvest will depend largely on the people the nurses choose to represent them on the various bodies that represent nurses and nursing. All too often nurses talk of ‘them’ and ‘us’, and blame the system and the elected or appointed 267

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nurses on various bodies when things go wrong, but do not actively participate in ensuring that the ‘them’ are the correct leaders. Nurses need to exercise their right to vote for nurse leaders who can speak on their behalf and who are knowledgeable, influential and prepared to take up the cause of nurses and nursing. Nurses need to support and lobby those leaders, and monitor their actions to ensure that they act in the interests of and on behalf of the profession and the community we serve.

Conclusion If nurses are to cope with the emotional pressures of the nursing professional, it is important the they develop a strong sense of their own identify and value system through deep introspection about critical issues. In developing their own strong and positive personal identities, with the sense of acceptance and security that goes with it, nurses will develop a sense of pride, not only in themselves but in what they can offer their patients and colleagues.

Suggested activities for students Activity 15.1 Outline your strong characteristics that supported your choice of career.

Activity 15.2 Nurse Beauty suffered a needle-stick injury, which was reported in good time and the necessary procedure was followed. Two months later she tested positive for HIV and is now claiming compensation. Working in groups of not less than three, answer the following questions: • What are the questions you need to ask? • What are the questions you needed to have asked in the first instance when she presented with needle-stick injury? • What are her rights as opposed to those of her employer? • What are the ethical as well as legal implications in this case?

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chapter

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Basic life skills for the nurse

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate knowledge and understanding of the self during interaction with others. • Demonstrate effective communication between individuals, families, groups and community members, irrespective of culture, when rendering holistic nursing care. • Demonstrate good interpersonal relationships in his or her daily contact with the patient. • Demonstrate the ability to utilise decision-making processes in personal life and when rendering holistic nursing care. • Demonstrate knowledge and understanding of the steps of the problem-solving process. • Demonstrate knowledge and understanding of assertive behaviour in personal and professional life. • Demonstrate knowledge and understanding of the principles of conflict management to address problems during healthcare delivery. • Demonstrate an understanding of the principles of conducting an interview/ counselling session.

Key concepts and terminology Assertive behaviour: The way individuals express themselves respectfully, honestly and directly without undue anxiety or belittling others. Communication: The exchange of information, ideas, beliefs, feelings and attitudes between two or more people. Conflict: A natural disagreement that results from differences in groups or individuals’ attitudes, beliefs and values, past rivalries or personality differences, or lack of information. Counselling: The provision of information to a patient with organisation of the information, therapy and the involvement of the patient as important aspects of the session. Decision making: The process of selecting among alternatives the best possible action to meet desired goals. Empathy: The ability to understand and share the experiences, emotions and feelings of another person/the ability to imagine what someone else might be thinking or feeling.  ➙

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Self-acceptance: The degree of respect individuals have for themselves, with consideration of their own strengths and weaknesses. Stress: A state of mental or emotional strain or tension resulting from adverse or demanding circumstances.

Prerequisite knowledge The nurse should have knowledge of the following: • Batho Pele principles • Patients’ rights.

Medico-legal considerations • According to the South African Nursing Council’s scope of practice, the following are essential: –– adhering to the principles of effective communication during an interview/ counselling session and the rendering of holistic nursing care –– assessing the reaction of the patient to treatment by using knowledge and understanding of life skills during the rendering of holistic nursing care. • During therapeutic interaction, when the feelings of the patient are interpreted, the nurse must show empathy and must not be biased.

Key ethical considerations • Nurses must apply basic life skills with caution as there are situations where they must take the lead in the care of patients without leaving them feeling that their basic human rights have been ignored. • Nurses need to be assertive during the rendering of holistic nursing care and must be aware of the possibility of appearing aggressive if decisions need to be made that might not coincide with the wishes of the patient. • It is necessary to show empathy when communicating with patients to maintain a trusting and caring relationship.

Introduction Interaction with individuals, family, friends, acquaintances and patients, including significant others, needs basic life skills. In the context of this chapter, life skills are considered to be the personal and interpersonal skills necessary to practise effectively as a nurse. These skills include self-awareness, assertiveness, communication skills, and stress and time management. Life skills offer the nurse an opportunity to acquire self-knowledge, take a positive approach to life and develop personal growth and enrichment. Interpersonal skills place emphasis on the individual as a unique person, and on interaction with the family, group and community. Nurses are responsible for 270

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their own personal and professional growth which will enable them to act appropriately towards other people, and to render holistic nursing care and support to their patients in the pursuit and maintenance of physical, mental and spiritual health. Life skills empower the nurse to develop and enhance a compassionate attitude when caring for patients. These skills enable the nurse to listen beyond what the patient is saying, and to be assertive, manage conflict and make carefully considered decisions. Life skills help to develop emotional maturity, which includes honesty, openness, loyalty to people present and absent, kindness, keeping of promises and confidence.

Attributes of life skills Self-analysis Self-analysis provides the individual with the opportunity to change potential failures into triumphs by analysing the effort put into the tasks carried out. By reviewing the evidence of these tasks, the individual can modify behaviour to ensure success. Self-analysis therefore assists in setting realistic goals. The individual’s potential is bigger than what is believed or what the individual is allowed to believe. Through selfanalysis, this potential can be recognised and realised (achieved). Individuals should take time to ask what they want out of life, what they are afraid of, what gives them joy and satisfaction, and what helps to achieve the set goals. Self-analysis leads to selfknowledge, self-acceptance and a positive self-image. Self-knowledge

Self-knowledge enables the nurse to be aware of his or her own attitudes, needs, personality style, interpersonal assets, strengths, weaknesses and talents. Personality represents the individual’s own unique identity. An individual’s unique humanity is displayed during interaction, socially and professionally, and thus it is important that a person understands and develops his or her own mode of behaviour as it contributes to secure interpersonal relationships. The value of self-knowledge lies in establishing positive interpersonal relationships by means of horizontal (between peer groups) and vertical (with seniors) communication in order to reassure, promote and maintain mental health, not only in the individual but also in others. The individual can make use of the Johari window (see Figure 16.1 on the next page) to develop self-knowledge, as this gives a presentation of the person as a whole. The four quarters or window frames represent the different areas of the total person – that is, everything known about the self and what other people know about the person as well as areas that are unknown to the person and to others. The individual’s aim is to enhance the areas known to the person through self-analysis and information gathered from others. The ideal is to enlarge the open area, which is the area known to others as well as the individual, as much as possible. This can be achieved by minimising the hidden area by telling those close to the individual about unknown aspects so that they get to know the individual better. The horizontal axis then shifts down, and the open area becomes bigger. The individual must feel comfortable with sharing the information. It is important to realise that this does not mean everything about the individual should be revealed, but that the individual should learn to trust those close to him or her with secrets and personal affairs. Nurses expect patients to give information that they may 271

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be uncomfortable with sharing, and they must be empathetic in approaching patients for the gathering of data during an interview or counselling session. Known to self

Not known to self

Known to others

Open

Blind

Not known to others

Hidden

Unknown

Figure 16.1  Johari Window (Luft 1984) The blind area could be minimised by the individual trying to learn more about the self from what others tell him or her. It becomes easier, as the people close to the individual feel free to give information if the person has already ‘opened up’. The vertical axis will therefore eventually move to the right, and the open area will become even larger. The ideal is to minimise the unknown area through self-examination and information from others. Table 16.1 depicts the utilisation of the Johari Window. Table 16.1  Schematic presentation of utilisation of the Johari Window Area

Area known to me

Area unknown to me

Area known to others

OPEN AREA Things others and I know (eg I have a sense of humour)

BLIND AREA Things I do not know but other people do (eg I frown when I am concentrating)

Area unknown to others

HIDDEN AREA Things I know (eg I am scared of the dark, but no one else knows it)

UNKNOWN AREA Things neither others nor I know (eg I have the ability to do carpentry, but I live in an area where I was not exposed to the skill and therefore have never developed it)

Self-concept

Self-concept is the way the individual views (sees) him- or herself. In adults, selfconcept is a complex and organised idea of the person as a whole, and includes physical, cognitive, emotional and social aspects. Self-concept means that a person not only has ‘knowledge’ of own characteristics but also has feelings about the self and characteristics. These characteristics are mostly formed by other people’s evaluation of the individual. Self-concept therefore includes such matters as self-image, self-esteem and self-acceptance (Louw 1990, in Geyer, Mogotlane & Young 2009: 291).

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Self-esteem and self-confidence are the basis for positive interpersonal relationships, mental health and maturity. Acceptance of personality traits and a realistic perception of abilities and acknowledgement of faults, as well as acceptance of bodily appearance, provides the pathway to a better understanding and acceptance of the self. Selfknowledge enables the individual to be aware of own attitudes, needs, personality style, interpersonal assets and talents. In the pursuit of positive self-esteem and selfconfidence, the individual must continuously examine his or her own feelings, attitudes and actions. The value of self-knowledge lies in establishing positive interpersonal relationships by means of horizontal communication (between peer groups) and vertical communication (with seniors) in order to reassure, promote and maintain holistic health. Self-knowledge has the following advantages: • Personal enrichment and development, with the enrichment of the person as a unique individual with unique attributes • Social development, where there is development as a social being in order to take a meaningful place and role in society. The person as an individual socialises with other people. During the socialisation process, the individual exerts a degree of dominance. The depth of domination (authority or control) and sociability (intimacy or friendliness) lies in the unique personality of the individual, as most people tend either to take charge (high dominance) or to allow other people to do so (low dominance). In the same way, people tend to be very warm and personal (high sociability) or somewhat cold and impersonal (low sociability) towards other people (Poggenpoel 1984, in Geyer, Mogotlane & Young 2009: 291). Self-image

Self-image is the image a person has of him- or herself as he or she ‘is’, as he or she ‘ought to be’, and as he or she ‘would like to be’. The individual’s self-image starts to develop at home, in the pre-school years, in church and at formal school mainly depending on what the child is told. Self-image changes as the individual encounters the demands and influences of society. Positive remarks to a child such as: ‘You are beautiful, very friendly and helpful’ will lay the foundation for a positive self-image and self-confidence. The demands of the nursing profession also have an influence on the formation of the nurse’s self-image. Praise for a task well done (eg meeting the needs of a patient) will build a nurse’s positive self-image. Through self-motivation and self-revelation, the individual will be able to change to become, within realistic limits, more like the ideal self (the person the individual would like to be). A person with a positive self-image continuously works at thinking positively about the self, and is therefore able to reach out to others confidently, communicate openly and encourage other people to acquire a positive self-image. An individual has a degree of objectivity about the self (who he or she is) and an assumption about a realistic level of aspiration (what he or she wants to achieve), which may change as the person grows older. Table 16.2 overleaf shows a presentation of the ideal self.

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Table 16.2  Schematic presentation of the ideal self Ideal self Self-image

Self-expectation

Self-evaluation

The way I see myself (eg I am diligent)

The person I would like to be (eg I am eager to do tasks delegated to me and will volunteer for other tasks)

The person revealed through my behaviour (eg I complete my assignments before the due date and volunteer to carry out tasks)

The person that other people see (eg My lecturers and family told me they appreciate the fact that I always try to be on time and do more than is expected of me)

An individual might at times experience a negative self-image. The following actions can be taken by a person to improve self-image: • Make a list of all strengths and limitations, but do not be too hard on yourself. • Be appreciative of good qualities and develop them further by painting a positive picture of yourself in your own imagination, for example: ‘I am a friendly person’, and by giving positive messages, for example: ‘I can pass this test if I study.’ • Change the limitations (weaknesses) that can be changed, for example: ‘I am not completing assignments on time; from this moment I will keep to due dates.’ • Be realistic about your own abilities and do not have an unrealistic expectation of them, for example: ‘I cannot have a career in music because I do not have the talent and ability.’ • Accept the limitations that cannot be changed and make peace with them, for example: ‘I am not good at sports, but I enjoy watching and supporting my team.’ • Be purposeful by setting goals, for example: ‘I am going to achieve success in my studies, by setting myself realistic goals.’ • Establish clear objectives and strive to achieve them, for example: ‘I want to complete my training in four years and must study every day to pass all my tests and the examination.’ • Make choices and take decisions, for example: ‘I can choose between becoming a nurse or an accountant, but I want to work with people, therefore I choose to become a nurse.’ • Accept responsibility for choices and decisions, for example: ‘I did not expect the course to be this difficult, but I will not give up.’ • Strive for higher inner norms and values, for example: ‘I am going to give some of my time and abilities to better the lives of the people who are in need of my services.’ • Be modest, for example after receiving the trophy for the best academic performance, do not boast about it. Self-acceptance

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who has self-respect will respect others. An individual who has difficulty in accepting him- or herself has difficulty in accepting others. The nurse has to accept the patient as an individual during the rendering of nursing care. The individual experiencing a change in the body image due to disease can experience a change of self-image, and the nurse must help the patient to accept the changes in the body structure brought about by disease by explaining its pathophysiology to the patient.

Communication The word ‘communication’ is derived from the Latin communicare, which means ‘to join, connect, impart, take part or unite’. In communication, there is an exchange (giving and receiving) of information, ideas, beliefs, feelings and attitudes between two or more people. When communicating, the individual is an active participant in the communication process. It can be verbal (ie speaking: word of mouth and the written word), and non-verbal (ie facial expression, postures, success or failure, looks, grooming, gait, lifestyle, possessions, area of residence and cultural heritage). Communication can take place interpersonally (between people) and intrapersonally (within the self). During communication, both parties must make the message clear and listen attentively. Communication must be accurate and dynamic, and any misunderstandings must be clarified. Communication is the pathway to achieving success in providing holistic nursing care. The richness of communication, with actions, sounds, symbols, attitudes and thoughts, is the basis of all relationships the individual has. It reinforces the bond between individuals, groups and communities. Individuals convey through communication their strengths, weaknesses, the way they view other people, their goals and objectives, needs, dignity and other human aspects. This communication should be beneficial to all involved, which is the ideal, but sometimes it can be harsh, aggressive and negative. During communication, all parties must give and receive a clear message and listen attentively to the message of the other parties. Effective communication is central to interaction with family members, friends and patients, and must be accurate and dynamic, and clarify any misunderstandings.

Factors that influence communication Effective communication requires interaction facilitated by eye contact, listening attentively and time in terms of appropriateness as determined by the receiver of the information communicated. If communication is unsuccessful, this may result in inappropriate behaviour as a result of anger or frustration, such as withdrawal or shouting. This behaviour is seen as an alternative expression of needs and must be interpreted as such. During the lifespan, the individual will communicate with people of all ages. It is important to remember to communicate on the level of the individual. Communication is influenced by the following factors: • Physical problems – for example, hearing impairment, visual impairment, speech impairment, expressive impairment (speech and language difficulties), dysphasia (speech errors) and dysarthria (problems in movement of the larynx during forming sounds) all affect communication.

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• Language – for example, for verbal communication to be successful, a shared language is needed, and therefore the help of an interpreter can enhance communication where a language is not shared. • Developmental stages – for example communication with a child requires simplicity, while conversations with an adult must be focused and clearly understandable. Where possible, the language used should be the choice of the individual addressed. • Gender – for example, females use communication for confirmation, to minimise differences and to establish intimacy, while males use it to establish independence and to negotiate. • Values and perceptions – for example the individual’s personal standards and his or her personal view of an incident will affect communication. • Personal space – this is viewed differently by different cultures. In personal communication some prefer a physical distance that ranges from 40 cm to 1 metre, while for others it is 1–3 metres, especially in social communication in a sitting room. During intimate communication, such as with people in an intimate relationship, touch and cuddling are preferred with a distance of about 40 cm. Communication in public, such as lectures with a large group, requires a personal space of 3–4 metres. • Territory – for example, when a patient is lying in bed with the curtains closed, this environment is perceived by the patient as a private one, and permission should be asked to make any changes. • Social roles and relationships – for example, the individual’s relationship in terms of seniority, circumstances (eg the nurse in charge) and familiarity (eg friends) will influence communication. • The environment – for example, a comfortable and quiet environment is conducive to communication. • Congruency – for example, a positive answer accompanied by a smile shows congruency between the spoken language and body language. • An interpersonal attitude – for example, a caring, warm, respectful and accepting attitude has a positive influence on communication.

The communication process An essential form of communication for the nurse is record keeping, and therefore it should be factual, accurate, consistent, honest, as thorough as possible, and written as soon as possible after the event. Records should be clearly written and non-erasable, show the accurate time and date, and they must be signed. Any alterations must also carry a legible signature, and must include the date and the time. Records should be free of jargon, abbreviations, irrelevant speculation, meaningless phrases and offensive subjective statements. Finally, records should be relevant, and should provide clear evidence of care planned, decisions made, care given and information shared. The communication process is an active one that involves the sender (known as the encoder), who has information to give in a form (code) that can be transmitted (sent) via the method chosen to convey the message (information). The receiver (known as the decoder) receives it, listens, absorbs the information and takes action by attending to the information. The receiver responds to the information by giving feedback. The process continues when a message or information is returned to the original sender.

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The message is the actual content of the communication and can be transmitted to the receiver in any form that involves the five senses of sight, smell, taste, touch and hearing. The content communicates ideas, norms and values, attitudes, goals and knowledge (information) to the receiver. A good communicator makes sure that the message conveyed is congruent in all aspects. For example, when a patient is being reassured by the words ‘I am here to help you’, this message must be accompanied by the full attention of the nurse. The method or channel of communication is the medium through which information is conveyed, such as the spoken or the written word. The nurse uses verbal and nonverbal communication through words, touch, tone of voice, intonation, body language, eye contact and facial expression as a method to convey information to the patient. Feedback is essential to determine the success of the communication. The receiver must understand, accept and indicate the portions of the communication that need to be clarified. During feedback, the communication can be verbal, non-verbal, negative or positive. During communication with a patient, the nurse must observe the feedback from the patient for congruency. For example, if a patient is told to go on a diet and the patient agrees, but the head is turned away or eye contact is avoided, the nurse could suspect that the patient will not adhere to the advice. The context of the communication is of importance. The environment, the social setting (ie formal or informal) and the social relationship between the individuals or groups, the emotional context of the communication, psychological factors, the cultural context (including norms, values and beliefs) and the temporal context (the time the communication takes place in relation to other activities) are all seen as the context of the communication. Various factors can interfere with the communication process. These include internal aspects such as the feelings and thoughts of the individual, stress and the individual’s ability to understand the information, and external aspects such as environment and physical comfort. Listening forms an essential part of communication, and is very important during communication in healthcare. Nurses must develop listening skills that will influence their ability to engage in therapeutic communication. Listening can have different functions. For example, when listening to music, it is to appreciate the music (appreciative listening). Informational listening is, for example, when listening to a lecture. Assessing or validating data is critical listening, and empathetic or therapeutic listening is listening to another person with a view to understanding his or her feelings or point of view. Communication can be barred by various factors, such as noise, inattentive listening, facing away from the patient and uncomfortable surroundings. The nurse must make sure that the environment is conducive to listening.

Forms of communication Verbal and non-verbal communication is used to convey information from one person to another. In verbal communication, the spoken or written word is used. It considers pace, intonation, simplicity, clarity, brevity, timing, relevance, credibility and humour. Non-verbal communication, on the other hand, takes the form of gestures, touch and body language, and considers personal appearance, posture, gait and facial expression.

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Therapeutic communication

Therapeutic communication is essential for the nurse to ensure holistic nursing care. It promotes understanding, it helps to establish a constructive relationship between nurse and patient, it is patient and goal orientated, and it needs time. The nurse responds to verbal and non-verbal communication through attentive listening that is active, sincere, energetic and unbiased. During therapeutic communication, the nurse concentrates on the communication, the speaker is not interrupted, the whole message is listened to and questions are asked for clarity. Physical attention is given by facing the other person, adopting an open posture and leaning towards the other person, but keeping the allowed personal space, maintaining eye contact and being relaxed. Communication with the individual who needs health information can take place through television, radio, newspapers and physical meeting. In urban areas, all these methods could be used, while in rural areas, the radio and physical meeting could be the most appropriate. Environmental communication

Communication in the caring facility is also important as the nurse should remember that the environment a patient is admitted into or counselled in communicates to the patient the type of care given at the facility. A clean facility with working equipment and friendly and knowledgeable personnel communicates a caring attitude towards the patient.

Potential barriers to communication The inability to communicate with and by the patient could influence the care given and could be caused by a language barrier, an illiterate patient who cannot read instructions, a patient’s physical disability (blindness or deafness) where appropriate assistive equipment is not provided, and a nurse who does not take into account the knowledge of the patient with regard to terminology and the patient’s disease when communicating with him or her. When communicating, it is essential to take the culture of the patient into account. The nurse must be aware that in the different cultures, aspects such as when to greet and talk can influence the way people view one another. In some African cultures, the elderly and more senior person speaks first, while in Western cultures, the younger and more junior person greets first. This could pose a problem when the nurse and the patient are from two different cultures – such as an African culture and a Western one – and the question arises of who greets first without letting the other person feel that he or she is not respected. In many cultures, the young person has to be invited to speak, but a nurse has to take charge even though he or she may be the younger person. In the nurse’s own culture it could be acceptable to show extreme emotions, although in the role of a nurse very strong emotions may not be displayed. The nurse is allowed to experience feelings of joy and grief, but these should be displayed in a dignified manner. Eye contact in Western cultures is seen as a sign of openness and honesty, while in African cultures, continuous eye contact, especially of a younger or junior person towards an older or senior person, is seen as a sign of disrespect. The nurse needs to maintain eye contact to be able to observe the patient for congruency between verbal and non-verbal communication. Gesturing and touching depend on

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the degree of intimacy between the communicators. Owing to the nature of nursing interventions carried out, the nurse needs to touch the patient during the rendering of holistic nursing care. Some of this could be embarrassing to the patient, and so the nurse must remember to ask permission from the patient to carry out nursing actions, such as a bed bath or offering a bedpan. The nurse uses touch when communicating caring, support and understanding to the patient, for example touching the hands, arms or shoulders of the patient during nursing care or when the patient is telling the nurse about his or her fears. Touching the hands of the patient while listening communicates a caring attitude towards the patient.

Decision making Decision making is the process of selecting from other alternatives the best possible action to meet desired goals. It can be personal and professional, and does not always imply that a problem exists. During problem solving, decisions are always made, and these are influenced by the value system of the person or people making them. When making decisions, the advantages and disadvantages of each one, Maslow’s hierarchy of basic needs, tasks to be delegated and priorities are taken into consideration through the critical thinking process, keeping in mind the ultimate goal. Each individual has to make countless decisions every day. The individual as a nurse and student makes decisions daily with regard to nursing care, confidentiality, studying, time management, scheduling of activities and prioritising of actions. The decision-making process is a systematic process of coping with matters of concern to the individual or group. For effective decision making in solving a problem, the problem needs to be defined. This is done by identifying the actual problem (eg breathlessness in a patient with a medical diagnosis of pneumonia). Gathering all the information needed to identify the problem will assist in determining the actual problem. Assessment of the information helps to prioritise the information and develop alternative solutions. Choosing the best solution will help to solve the problem. After the decision is made on a specific action, the action is implemented. A follow-up or review of the action is done to evaluate whether the problem was solved or whether the steps taken need to be reviewed. Reviewing of the process helps the individual to identify own strengths and weaknesses regarding the decision-making process and to identify more appropriate methods of solving problems in the future. To ensure successful and appropriate decisions are made, the individual or group has to follow the steps in the decision-making process. These are outlined in Table 16.3. Table 16.3  Steps in the decision-making process Step

Action

1. Identify the goals and objectives of the decision

Decide what must be done, and identify the reason for the action

2. Set the criteria for the decision

Ask the following questions: • What is the expected outcome? (eg normal breathing) • What needs to be done? (eg assist the patient to assume Fowler’s position) ➙

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Step

Action • What needs to be avoided? (eg unnecessary movement of the patient)

3. Weigh the criteria

Prioritise for the specific situation the criteria that are important (eg normal breathing)

4. Develop alternative actions

Identify all possible ways to achieve set goals, for example • loosen tight clothing around the chest • open nearby windows if allowed to facilitate ventilation • give oxygen

5. Evaluate alternative actions

Analyse each alternative action to determine whether it will solve the problem, and identify the consequences of each alternative

6. Project

Apply critical thinking strategies and scepticism by asking yourself questions to prevent problems, minimise problems, overcome problems and assure safety and satisfaction for everybody involved, for example: • What will happen if I …? • How can I …? • How do I feel …? • How does the patient feel …? • What would the consequences be …? • What am I going to do …?

7. Implement alternative solution decided on to reach the goal

Take action by implementing the decision and be confident that the decision is the right one to take, for example maintain Fowler’s position

8. Evaluate the outcome

After implementation of the decision, assess the result of the decision against the goal set at the beginning to determine effectiveness and goal achievement, for example normal breathing at a rate of 16–20 breaths per minute

Clinical alert! In an emergency situation, decisions regarding the care given to a patient are of the utmost importance. The nurse cannot afford the time it might take to establish a therapeutic relationship with a patient before a life-saving action is carried out. The golden rule is to remember that the rights of the patient should be maintained at all times.

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Nursing implications • The nurse should take care not to make life-changing decisions about the patient without the involvement of the patient and the significant others while rendering holistic nursing care. • The nurse should demonstrate assertiveness without being overconfident or aggressive while rendering holistic nursing care, taking into consideration the rights of the patient and the members of the multi-professional team. • The nurse should be careful not to project own feelings on the patient during communication with a patient.

Problem solving Problem solving is part of daily personal and professional life, because problems arise when people believe there is a difference in their reality. Problems must be seen as opportunities that may lead to growth and development, rather than insurmountable obstacles against which one is helpless, therefore it is important to develop a problemsolving attitude towards problems in general. The attitude includes, amongst other things, doing the following: • Recognise that problems are a normal part of the everyday life of all human beings as opposed to thinking that you are the only one having problems. • Believe in your ability to solve problems. • Be willing to acknowledge problems as they arise and immediately look for solutions. • Acquire more effective management skills in place of impulsive behaviour. The nurse faces the challenge of managing life’s problems in a constructive way. Skilful problem solving and management mechanisms help to achieve the objectives of reducing stress and reaching goals. Solving problems is a daily occurrence – some problems could be life threatening while others, if not solved, could cause an inconvenience. In solving a problem, the individual or group needs to find out more about the problem by asking questions, for example: ‘Have I encountered this problem before, how is it similar or different from other problems, and what do I know about this specific problem?’ Choosing a strategy to solve the problem is important and will assist in the process by assessing the method previously used to resolve similar problems or deciding on a strategy. In looking back and revisiting the problem, the degree of success in the solution decided upon can be determined and if the problem has not been solved, an alternative can be examined. It is important that one should understand the problem one has to solve in order to describe it accurately and in the correct terms. A problem that is stated well is a problem half solved. People who are able to manage their daily problems well usually have the ability to describe vague ideas in concrete terms. For example, instead of saying: ‘Everything is too much for me’, rather say: ‘I do not have enough time to cook, iron, do the washing, look after the children and study as well’. Note that the second description is a more concrete description of the problem than the first statement. A good strategy is to write down the problem, as this compels one to be more specific. Problem solving includes a form of decision making. In order to solve a 281

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problem effectively, one has to deal with it systematically by working through the following steps: 1. Identify the problem. 2. Write down the problem to encourage problem solving, for example: ‘I am always late for classwork’. 3. Describe the reasons for the problem. A clear description will assist in identifying the problem more effectively, for example: ‘Because I am always late for class, I am excluded from the information discussed in classes/on patients’ rounds.’

Seeking alternatives The more alternatives identified the better chance of solving the problem, for example, ‘I can get up earlier’, or ‘I can ask somebody to give me a lift’, or ‘I can get everything ready the day before’. Think of as many alternative types of behaviour or alternative solutions as possible, no matter how absurd or unacceptable they may sound. Write them down. At this stage no judgement of the alternative possibilities is made. The ideas are written down as they occur. The purpose is to learn to think without prejudice. The following principles are important: • Delaying impulsive action allows consideration of all possible alternatives. • Quantity produces quality – the more alternatives found, the better the possibility of a workable solution. Making the decision This takes place in two phases, namely choosing the strategy and working out the tactics. Distinguish between strategy (what is going to be done that is more general, for example: ‘I must be on time for my classes/work)’, and tactics (how it is going to be done, which is more specific, for example: ‘I am going to get up earlier in the mornings’): • Choosing the strategy (what must be done) means considering every alternative on the basis of personal, social, and short- and long-term consequences. • The tactics (how is it going to be done) comprise a plan of action that must be worked out after a specific alternative has been chosen. Implementing chosen strategy and tactics After deciding on your strategy and tactics, start implementing the decision, such as getting up earlier in the morning. Evaluating the outcomes It is important to follow through with your decision. Do not start to hesitate, worry or go back on what has been done previously. Do not doubt the correctness of the decision; carry on implementing your choice. After implementing your choice, determine its success. If the outcome is satisfactory, the problem has been solved. If the result is unsatisfactory, identify and write down the problem again to begin problem solving. Weigh up all the alternatives again, make another decision and implement your new choice.

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Using functional thought If the results are satisfactory and the problem has been solved, praise should be given to the self and/or others, for example: ‘I can do it. I can manage problems if I give myself the chance, I solved this problem and I can feel good about it’. This will boost confidence to try to solve other problems. If the results are unsatisfactory and the problem has still not been resolved, it is important to remember that not all problems can be solved. A solution cannot always be perfect and does not have to be perfect. Sometimes compromise is needed to prevent other people from being negatively affected. Good problem solving often means giving in to oneself and others, and setting a less attractive or ideal alternative. Functional thought is necessary in these cases. The individual is not worthless because he or she has failed. Everybody cannot succeed all the time. Everything cannot be perfect all the time. If the problem still requires attention, describe the reasons for the problem and try again. Table 16.4 presents the application of a problem-solving strategy. Table 16.4  The application of a problem-solving strategy Steps

Strategies

1. Define the problem

a. Ask the following questions: • What caused the problem? • What is happening? • How is it happening? • When is it happening? • With whom is it happening? • Why is it happening? b. Describe the problem in five sentences.

2. Identify the causes of the problem

a. Write down your own opinion. b. Get input from all people affected by the problem, one at a time. c. Seek advice from a peer or supervisor. d. Write down a description of causes of the problem in terms of the following: • What? • Where? • When? • How? • With whom? • Why?

3. Identify alternatives to solve the problem

a. Brainstorm for alternatives. b. Write down all possible solutions without judgement. c. Assess alternatives.

4. Select a solution

a. Consider the approach that is most likely to solve the problem. b. Are there resources to apply the solution? c. What is the extent of risk involved in applying the solution? ➙

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Steps

Strategies

5. Implement best alternative

Consider the steps, systems and processes needed for a specific solution.

6. Assess implementation of the alternative

Assess the process of implementation according to the steps decided on.

7. Assess whether problem was resolved

a. Assess whether normal functioning has resumed. b. Assess avoidance of the same problem in future. c. Assess knowledge gained from resolving the problem.

Assertive behaviour This behaviour enables a person, as an individual and a nurse, to set own objectives, to achieve goals and to take responsibility for own actions. An assertive individual is always polite, has good manners and has respect for other people and him- or herself. Assertive behaviour implies that the individual’s rights are set and maintained without denying or infringing on those of others. When individuals come into contact with their strengths and limitations, this enables them to know who they are, where they are going and how they are going to get there. Individuals display certain characteristics during their interaction with other people, which can be described as assertive and non-assertive behaviour. The ideal is to be assertive in all behaviour and situations. Assertiveness is displayed through verbal and non-verbal communication used by the individual. During verbal communication, assertive individuals think and speak positively of themselves, uses ‘I’ messages, initiates discussions, and learns to give and receive information with grace. Assertive people can give information regarding themselves (self-exposure), give constructive criticism and accept personal criticism. They can make a statement without explaining, discuss feelings and express negative ones. Assertiveness is shown in perseverance, in the use of the exact words and in giving and receiving compliments with grace. Assertive people also acquire protective skills whereby they protects themselves without hurting others. The nonverbal communication of assertive people reflects respect for the others’ physical distance (personal space), and they are aware of their posture and use spontaneous hand movements. Eye contact is easy to establish, and congruent facial expressions are used. Such people concentrate on speaking smoothly and take note of the content of conversations. Passive and aggressive behaviour are related in the sense that both are the opposite of assertive behaviour. At different times, people may make use of either aggressive and/or passive behaviour. Passive behaviour implies that they allow others to infringe on and determine their rights. Non-assertive people allow others to choose, decide and talk for them, which leads to feelings of inadequacy and insecurity. The hurt is turned inwards, and depression, self-blame, self-punishment and self-disgust arise. Such people tend to be defensive, quiet and frightened. Passive and aggressive behaviour is reactive rather than purposeful, and both types of behaviour reflect underlying insecurity, indirect communication and the inability to take responsibility for one’s own actions and feelings. 284

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Aggressive behaviour can be perceived as trying to control or manipulate other people. Aggressive people state their opinions in a rebuking, threatening, attacking, demanding and hostile way. They deny and infringe on the rights of others, and are without empathy. They intimidate other people through verbal attacks, humiliation or guiltinducing remarks. To become more assertive, individuals can learn to do the following: • Trust their own judgement. • Take the responsibility of saying ‘no’ when they cannot or do not want to do something. • Give a reason for this, but not an excuse. • Give sufficient information when asked to prepare, comment or do a presentation, or when saying ‘no’. Table 16.5  Differences between assertive and aggressive behaviour during a conversation Assertive behaviour

Aggressive behaviour

Let’s talk about this and come to an agreement.

You obviously don’t know what you’re talking about and must do what I tell you to do.

The agreement was that your report would be available today.

Your report should have been completed. If I do not have it on my table in 10 minutes I am going to take further steps…

I cannot help you now, but I will be able to in an hour.

Can’t you see that I’m busy? Go away!

I don’t like being shouted at. If you want to talk, I would be interested in discussing the matter.

Don’t shout at me! I don’t want to listen to you!

A nurse may encounter situations where the rights of the nurse as an individual are infringed upon, such as being denied an off-duty weekend. For the nurse as caregiver, the rights of the patient to continuous care are paramount and thus the person in charge of the care facility will first ensure the rights of the patient are protected before the rights of the nurse as an individual are upheld. It is important that the rights of other individuals are not infringed upon when asserting own rights, as this can be interpreted as aggressive behaviour. Individuals have the right to the following: 1. State their own needs and set their own priorities whatever other people expect of them because of the different roles played in life. 2. Be treated with respect and dignity as intelligent, capable and equal human beings. 3. Express feelings, opinions and values. 4. Say ‘yes’ or ‘no’ when asked to do something (remember, however, that delegated work or assignments cannot be denied, for example not handing an assignment in because they simply did not want to do it). 5. Make mistakes, as long as they do not harm other people. 285

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6. Change their mind, and to give a reason, but not have to explain. 7. Say ‘I do not understand’ if confronted with new, changed or different information or circumstances. 8. Ask for what they want, as long as it does not harm other people. 9. Decide for themselves whether or not they are responsible, or have to take responsibility for another person’s problem. 10. Deal with people without having to make them like or approve of them. 11. Be accepted for who they are. Assertive behaviour is often confused with aggressive behaviour, but assertive behaviour does not intentionally hurt the other person physically or emotionally. It aims to balance power and not win the battle. Assertive behaviour involves expressing rights as an individual, expressing wants, feelings, needs and ideas, and giving other individuals the right to do the same. An assertive person opens the way for honest relationships with other people and for compromising and problem solving. Assertive people maintain eye contact and an erect posture, speak clearly and audibly, have congruent verbal and non-verbal communication, listen attentively to other people, know what they are talking about, are willing to listen to other people’s ideas, and are content with life. Assertiveness is a lifelong learning process and needs to be maintained throughout life. Assertive behaviour results in the development of own self-respect, as well as respect from others; not hurting others or oneself; in building positive relationships and forming new ones; in letting others know how one feels; and in standing up for one’s own rights without being selfish. It builds trust, and affords people the opportunity to change their behaviour if it infringes on others’ rights, and lets the individual decide what is important. Assertive behaviour lets you feel better about yourself, and it benefits all people you are in contact with. People who are not assertive feel they do not have rights and are not respected, they confuse assertiveness with aggression or passive behaviour, and they fear negative consequences in others, such as anger. They do not have the skills to say ‘no’, to make requests, to ask for a change, to give and receive compliments, or tell others that they care about them. They were taught (socialised) to be accommodating, selfless, accepting and undemanding, and thus they cannot communicate wants, feelings, needs and ideas, or they assume that others will know these without being told. The consequences of non-assertive behaviour are that the individual avoids conflict, appeases others, loses self-esteem, develops feelings of hurt and anger, and develops psychosomatic symptoms such as headaches, ulcers, backache and/or depression. Some people behave aggressively because they anticipate being attacked and therefore they overreact. They are initially passive, and their anger builds until they explode. They were reinforced in their aggressive behaviour by being given attention or given what they wanted. They cannot express wants, feelings, needs and ideas, and they were socialised to be in charge, competitive, ‘top dog’ and achievers. As a result they alienate other people, are lonely and feel rejected, and receive little respect from other people. They develop hypertension and ulcers, and other stress-related ailments.

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Table 16.6  Differences between passive, aggressive and assertive behaviour Passive behaviour

Aggressive behaviour

Assertive behaviour

‘You’re OK’

‘I am not OK’

‘I’m OK, you’re OK’

Is afraid to speak up

Interrupts and talks over others

Speaks openly

Avoids looking at other people

Stares at other people

Makes good eye contact

Shows little or no expression

Intimidates others with expression

Shows expression that matches the message

Slouches and withdraws

Stands rigidly, crosses arms, invades other people’s personal space

Relaxes and adopts an open posture

Isolates self from groups

Controls groups

Participates in groups

Agrees with others, despite own feelings

Only considers own feelings and demands from other people

Speaks to the point

Values self more than others

Values self less than others

Values self equally to others

Hurts self to avoid hurting others

Hurts others to avoid being hurt

Tries to hurt nobody (including self)

Does not reach goals and may not even know them

Reaches goals but hurts others in the process

Usually reaches goals without alienating others

Self-denying

Self-enhancing at other’s expense

Self-enhancing

Personal feelings suppressed/inhibited

Personal feelings expressed in negative/inappropriate fashion

Personal feelings expressed in positive/appropriate fashion

Closed and dishonest

Open, partially honest, but inappropriate

Open, honest and appropriate

Message vague at best

Message lost in expression

Message clear and direct

Does not say/do what he or she would like (goal not accomplished)

Says/does what he or she would like at the expense of others (goal accomplished at others’ expense)

Says/does what he or she would like in appropriate fashion (goal accomplished)

➙

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Passive behaviour

Aggressive behaviour

Assertive behaviour

Others choose for self

Chooses for others

Chooses for self

Feels angry at self, hurt, and/or resentful of others

Feels powerful, smug and/ or guilty

Feels good, confident, and respectful of self

Other person feels pity, disrespect, guilt and/or anger

Other person feels anger, resentment, disrespect, hurt and humiliation

Other person feels respect, appreciation, pleasure and/or surprise

Relationship cannot improve because of not sharing

Relationship cannot improve because of sharing destructively

Relationship can improve because of sharing appropriately

Ineffective in positively changing others’ behaviour

Ineffective in positively influencing others’ behaviour

Very effective in influencing and/or modifying others’ behaviour

An individual can develop assertiveness by speaking up when having an idea or opinion, standing up for own opinions and sticking to them, making requests and asking for favours, accepting and giving both compliments and feedback, questioning rules or traditions that do not make sense or do not seem fair, insisting on own rights being respected, saying ‘no’ and refusing requests if unreasonable, for example when he or she does not have the time or resources. Assertive individuals do not need to make excuses because they make sure where they stand first, and ask for clarification if they do not understand. If they are not sure whether they want to say ‘yes’ or ‘no’, assertive individuals take time to think it over and let the other person know when they will give an answer. Assertive people are as brief as possible when answering, and give a reason, not an explanation, for refusing a request. They use verbal and non-verbal communication to give the message, and say ‘no’ without feeling guilty about it. Once a request has been accepted, assertive people do not change their mind. The assertive individual becomes less aggressive by giving others a chance to speak, respecting the opinions of others, being diplomatic, choosing assertive language, avoiding bullying and demanding behaviour, and avoiding physically aggressive behaviour.

Empathy Empathy has been described as ‘walking a mile in another person’s shoes’. Empathy is a process in which a person is able to see beyond the outward behaviour of another individual and sense the other’s inner experience accurately at a given time. Through empathy, the nurse accurately perceives and understands the meaning and relevance of the patient’s thoughts and feelings. Empathy is the identification with and understanding of another’s feelings, motives and situation; it is the ability of the individual to imagine him- or herself in the place of another person and understand that person’s feelings, desires, ideas and actions. Being empathetic involves putting one’s own feelings aside

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to help others. To be able to understand the patient’s position is one of the most important skills a nurse can have. The nurse must communicate this understanding to the patient and attempt to translate these perceptions of feelings and behaviour into words. It is not uncommon for the concept of empathy to be confused with that of sympathy. The major difference is that with empathy the nurse accurately perceives and understands what the patient is feeling, and encourages the patient to explore these feelings. With sympathy, the nurse ‘shares’ what the patient is feeling, and feels a need to alleviate distress. Empathy is a skill that requires practice, and the individual must develop and refine this skill throughout life in order to be able to focus on the feelings of others. Empathy depends both on self-awareness and awareness of the feelings, ideas, desires and actions of the other person. It also depends on a shared frame of reference. For example, individuals will not truly understand the feelings of others unless they have had similar experiences, such as having to have major surgery.

Nursing implications Empathy and listening skills could lead to good interpersonal relationships. However, there may be challenges when applying these skills in the rendering of holistic nursing care. The nurse, while listening, could become depressed through the despair the patient is experiencing by reliving a harrowing experience of his or her own if a patient talks about a similar kind of experience. Nurses could have feelings of guilt if they are not as empathetic as desired, especially towards people of another race or culture. In showing empathy, that person is supporting another, and it should be borne in mind that there are times when the nurse, as that person, also needs support.

There are four different levels of empathetic response, as presented in Table 16.7. The nurse, in interacting with the patient, strives to maintain the highest level of empathy, and this is a skill that requires practice. Table 16.7  Levels of empathetic response Levels of empathy

Actions/responses

response

Level 1 Inaccurate reflection or distracting comments

• Changing-the-topic response: A friend is telling you his brother is missing and you talk about the lunch you had with friends. • ‘I know better than you’ response: A friend is telling you that he or she is feeling depressed and you respond: ‘There’s nothing wrong with you. You’ll feel better tomorrow.’ • Judgemental response: A person tells you he or she did not study for the test and you say: ‘I hope you realise you will fail.’ • Advising response: Your sister tells you she is pregnant for the fifth time (she is 25 years old) and you tell her what doctor she should go to for family planning. • Discounting and premature reassurance: Your brother tells you his 13-year-old son has been caught stealing and you comment: ‘Oh, everybody tries their luck – don’t worry about it.’ ➙

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Levels of empathy

Actions/responses

response

• Psychoanalysis: A friend tells you she is afraid of being poor and you tell her it is because her father drank and squandered all their money. • Questions: A friend hints at some problem at work and you start the inquisition by saying: ‘What happened? Did you tell the boss?’ • Telling your own story: Your friend tells you about a problem that reminds you of a similar problem that you had. Level 2 Correct understanding of some of the other person’s feelings and circumstances, but other significant factors are misunderstood or overlooked

• The listener does not entirely understand the speaker’s feelings, which discourages the speaker from expressing more feelings unless the listener clearly indicates an interest in clarifying exactly what the speaker is experiencing. For example, your friend tells you that he is mad at his father (experiencing frustration and helplessness) and you respond with: ‘You feel like telling him how you feel’, and he responds with: ‘Oh no, I don’t want to make things worse.’ These misunderstandings could be caused by our own feelings, for example anger, insecurity, defensiveness or hurt.

Level 3 An accurate empathy response captures the essence of the speaker’s feelings

A friend visits you and tells you about the terrible day she has had and everything that went wrong, and your comment of: ‘You feel overwhelmed’ is answered with: ‘That is really how I feel at the moment’. You have put yourself in her shoes, and your comments reflect exactly what she has told you. When responding to someone with an accurate empathy response, you are brief and use your own words, showing that you are listening and caring. Be tentative, as empathy statements are really questions, for example: ‘You are feeling down’ really means: ‘Are you feeling sad?’ Comment frequently to make sure you still understand what has been said as this emphasises to the speaker that you are still interested in what is being discussed.

Level 4 Adding to the speaker’s selfunderstanding

Your sister tells you that she thought going to university would open the world, and you respond: ‘Could it be that you are feeling unsure because it is a new job, and because it is important to be a success, you feel scared of failing?’ You cannot always understand or guess what the speaker is feeling before the speaker has recognised and/or expressed his or her own emotions. The speaker may recognise the underlying emotion and accept the interpretation if the empathiser questions whether the speaker might be feeling a certain way. This could add to the speaker’s insight, awareness or understanding of his or her feelings and the situation. You need to be tentative in your response, for example: ‘Could it be ...?’ or ‘I wonder if ...?’

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Therapeutic listening and empathy show the other person that the caregiver cares, and the person will open up more. The nurse will learn more about the other person as any misinterpretations can be corrected immediately. The conversation is directed to important emotional topics. The speaker feels accepted and can talk about intimate, personal topics, and thus feelings are expressed and self-exploration can take place. Therapeutic listening and empathy reduce irritation, prejudice and assumptions because the listener understands the other person and can build more meaningful, helpful relationships. To develop empathetic skills, the nurse needs to be a good, active listener, who responds empathetically and practises giving emphatic responses. The perceived feelings of the patient must be assessed with care. The nurse should not presume to know what the other person is feeling, and the person must recognise his or her own feelings and react to them. Assumptions made about feelings could lead to the trust relationship between the nurse and the patient being disrupted.

Conflict management Conflict is an integral part of life, and it happens when there is a clash of ideas between people or parties. Conflict arises when the behaviour of one person blocks or interferes with the behaviour of another. Although people strive, where possible, to live peacefully with one another, certain situations are unavoidable and lead to conflict. Various factors including differences in approaching different situations and interests, and individual and group needs, objectives, norms and values, can lead to conflict. Conflict is a natural disagreement that results from differences in groups’ or individuals’ attitudes, beliefs and values, past rivalries, personality differences or lack of information. Conflict thus arises when the needs of an individual or group are ignored; when power is used to try to make people change their minds or to gain an unfair advantage; when situations are misinterpreted or values are incompatible, unclear or ignored; or when feelings or emotions regarding a topic are different or ignored. Types of conflicts include the following: • Intrapersonal conflict: This is a conflict that occurs within the individual person when having to decide between two or more important issues. • Interpersonal conflict: This happens between two or more people when they do not agree or see an issue the same way. • Organisational conflict. This is conflict that occurs between the employer and employees (management and subordinates), which may lead to a labour-related conflict if it is not solved and a dispute is declared. Conflict is perceived as positive if it is mutually beneficial and strengthens relationships, leads to growth and innovation, promotes creative thinking and generates additional options. The goal in conflict management is for all the parties involved to win, and at least some, if not all, needs are met. Constructive conflict management contributes to personal growth and reinforcement of cohesion in the group context. The steps in conflict management are as follows: Step 1: Analyse the conflict • Analyse the nature and cause of the conflict. • Ask questions. 291

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Step 2: Determine the management strategy • Analyse and select the most appropriate strategy in managing the conflict. • If necessary have a mediator. Conflict management strategies are described as follows: • Collaboration: Collaboration is generally regarded as the best approach for managing conflict. Collaboration results from a high concern for the interests of the group and of other partners. The desired outcome is ‘win/win’ for all parties involved. This result builds commitment and reduces bad feelings. It takes time and energy and some partners may take advantage of the others’ trust and openness. The objective of collaboration is to reach consensus. • Compromise: This strategy results from a high concern for the group’s own interests and moderate concern for the interests of others. The outcome is a ‘win/ lose’ situation for parties involved. It is used to achieve temporary solutions, to avoid destructive power struggles or when time pressures exist. Sight could be lost of important values, of long-term objectives and of the merits of an issue, and a cynical climate could be created. • Competition: The outcome is a ‘win/lose’ situation for parties involved as the strategy results from a high concern for own group’s own interests (win) with less concern for others (lose). It is mostly used when basic rights are ignored, and when a precedent is set and there is an attempt at bargaining. It can cause escalation of the conflict, and retaliation by losers. • Accommodation: This results from a low concern for the group’s interests (lose) combined with a high concern for the interests of other parties (win), and the outcome is ‘lose/win’ for parties involved. It is used when the issue is more important to others than to one, and when one recognises that one is wrong, this is seen as a ‘goodwill’ gesture. Own ideas and concerns could be ignored and one may lose credibility and influence. • Avoidance: This results from a low concern for the group’s own interests and for the interests of others. The outcome is ‘lose/lose’ for all parties involved. It is used when the issue is trivial and there are others that are more pressing, when confrontation has a high potential for damage, or when more information is needed. It could lead to important decisions being made by default. Step 3: Pre-negotiation • Lay the groundwork for negotiations where conditions, rules and an agenda are set for the negotiations. • If necessary, a spokesperson and a facilitator are identified. • Meetings are arranged, and all role players are invited to attend. • Minutes of meetings are taken and distributed to assure all stakeholders are kept up to date. • Relevant facts and information are discussed. Step 4: Negotiation • Interests of the parties involved and possible solutions are discussed and decided upon.

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• A written agreement assures that these decisions are remembered, communicated and adhered to. • All stakeholders must be committed to honouring the decision made. Step 5: Post-negotiation • Implement the decision taken. Conflict management is enhanced if the stakeholders have negotiation skills, they incorporate people who are separate from the problem, develop options to solutions, do not judge prematurely, consider all stakeholders’ interests, and develop objective criteria for alternatives and different sources of information.

Coping with stress Every individual experiences stress in daily interactions with other people and during professional practice, and each individual reacts differently to the same stressors. Stress is relative to the pressure an individual is under and the recourses that individual has to cope with the stress. Stress can be positive, helping to achieve goals, or negative when it hinders goal achievement. Stress is experienced physically, mentally, emotionally and environmentally. Physical activity can be demanding and cause stress; development of skills can be mentally demanding; emotional stress could be caused by losing a loved one; and the changing home and work environment causes environmental stress. The question is how the individual can make sure that the stress experienced is a motivator and not an obstacle. Stress management can be achieved through having a positive view of reasonable stress and seeing it as a motivating factor that keeps the individual focused and energised, setting achievable goals, and regularly assessing stress levels and their causes.

How to manage stress Change aspects that can and need to be changed, plan ahead, take some time out and do relaxation exercises, take enough fluids and nourishment, and see stress management as a coping skill and not a sign of failure to cope. Stress management will enhance performance and in the long run assure success at home and at work. Non-management of stress may result in anxiety, depression and even more stress.

Warning signs of stress Warning signs of stress include fatigue, sleeplessness, drinking too much alcohol, not being able to concentrate, not being able to function properly, perpetual worry, bad temper, paranoia, feeling overwhelmed, eating too much or not properly, crying for no reason, loss of confidence, being agitated, panic attacks, withdrawal or isolation, feeling close to breaking point, confusion and forgetfulness. An individual experiencing all or most of these signs and symptoms is burned out and is clearly not managing stress. Stress can be managed on three levels: • Primary prevention, for example planning ahead and stating expectations clearly and what needs to be done ➙

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• Secondary prevention, for example improved diet and exercise, and relaxation exercises • Tertiary prevention, for example counselling after a traumatic experience. Owning up to mistakes, rectifying them, making correct decisions and developing adequate problem-solving skills can be helpful in preventing and managing stress.

Coping with stress is essential for the nurse in dealing with everyday challenges. There are several strategies that can be implemented to manage stress. Examples are touching and massaging an anxious individual to reduce the anxiety; staying positive; concentrating on the activities one can do, and getting advice and help for those that one does not have the skills for or cannot cope with; and maintaining control over situations. All individuals are exposed to stressful situations throughout their lifespan, all of which could lead to feelings of tension and stress. These feelings can be managed positively (coping mechanisms) or negatively (defence mechanisms). Defence mechanisms include negative behavioural reactions such as adjusting goals to what seem more achievable, avoidance, denial, aggression, rationalisation, and developing psychosomatic signs and symptoms. To cope with a stressful situation, the individual needs to identify the causes of stress and the signs of not coping with stressful situations. These signs include intrusive thoughts such as: ‘I can’t do the work’ (cognitive response), feelings of sadness or fear (emotional response), rapid heartbeat (physical response), and destructive behaviour such as drinking too much alcohol or not eating (behavioural response). The next step would be to calm down, do deep breathing exercises, think reassuring thoughts, relax tense muscles and ask for help when needed. Stress in itself can be a motivating and focusing factor, as long as the individual guards against stress becoming a barrier against normal functioning. This can be achieved by employing various coping mechanisms. Coping mechanisms include relaxation techniques, but as there is a great variety of these suited to individual personalities, a discussion of them is beyond the scope of this chapter. We shall focus on a discussion of time management as an essential and practical coping mechanism.

Time management Time management is essential for the nurse to ensure that all nursing outcomes are met according to importance or relevance of the outcome. Time management is not only applied professionally but also personally to ensure professional and personal success, and it can contribute to the alleviation of stress in the professional and personal life of the nurse. Managing time has advantages such as gaining time to do all the activities needed. It motivates and initiates task management, reduces avoidance of tasks, promotes review of partially and completed tasks, eliminates cramming when studying or preparing a presentation, and reduces anxiety. Time is one of the most precious commodities an individual has, but it is unfortunately non-refundable, non-reusable and non-renewable, thus the individual must learn to use it effectively. The perception of the varying rate at which time passes is an illusion due to the relativity of the perception of time. For example when we enjoy an activity, 294

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time seems to fly, but when we wait for somebody, it seems to pass slowly. To enable the management of time more effectively, the individual has to examine attitude and beliefs regarding time. Mastering inner time management or the way in which time is perceived needs an understanding of real time and felt time, how cultures view time (eg ‘professional time’, ‘Western time’ and ‘African time’) and how time affects performance. Developing a constructive attitude towards time, and organising and adopting appropriate systems and strategies will help to use it effectively. Effective time management can be assured by identifying the priorities of the tasks to be fulfilled, such as ‘urgent’, or ‘tomorrow’ or ‘can wait’, and by determining the goal of the tasks and how they contribute to reaching the goal. A time management grid will help to categorise the tasks. The more difficult the task, the more time should be allocated for its completion, and more time than is anticipated should be added to cover unforeseen circumstances such as illness. The grid should be updated every day and whenever a task is completed. Create a time schedule that suits lifestyle and activities as this will give flexibility to ensure time is spent on activities that are important. Create ‘to-do’ lists and calendars with tasks and appointments pencilled in to assist in the prioritising of tasks. Use the time management grid to carry out the tasks as prioritised. After prioritising projects, break them down into manageable tasks and update the plans as necessary. Set the time required for completing the tasks to assist in planning. Plan for unexpected changes such as illness or due dates that change. Periodically ask what the best use of time would be at that specific time. Table 16.8  Time management plan Urgent

Tomorrow

Can wait

Make a doctor’s appointment for baby

Prepare for special dinner tomorrow at 20:00

Buy material for matric dance dress

Study for test tomorrow

Get together information for assignment

Prepare assignment for due date

The nurse, as a student and adult learner, has to prioritise other responsibilities with the responsibility of studying and therefore needs to strategise studying time by developing blocks of study time, scheduling weekly reviews and rescheduling where necessary, and prioritising assignments (beginning with the most difficult tasks or subject). Develop a study place free of distractions to maximise concentration and time utilised. Plan activities for revitalisation, and include rewards for tasks completed, for example go for a walk or visit with the family, keeping time management in mind. Review lecture material immediately after class to identify problem areas and to aid memorisation. Review study material and preparation just before class, and schedule time for critical events such as presentations and tests. Ignoring tasks and procrastination will not make tasks go away but will result in crisis management and stress. Do not always start with the easiest or the most pleasant tasks first; the most important one should be completed first. Conversations, meetings and interruptions are common time wasters; develop communication skills to help stay focused. Set time limits and make the other people involved aware of the time 295

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constraint for an activity. Group tasks together that are similar, make decisions quickly, delegate tasks, be assertive and recognise when to say ‘no’, handle paper only once and, where possible, trade tasks.

Interviewing and counselling The interview with a patient is the provision of information, with timing, organisation of the information and counselling that includes the involvement of the patient as an important aspect of the interview. A patient who is not ready to impart or receive information will not contribute to the success of the interview or counselling session. The right timing of the interview or counselling will contribute to the amount of information the patient understands and remembers. When giving information, the developmental stage, mental ability and the physical health status of the receiver must be taken into account. The patient knows his or her life, and the advice given must complement the patient’s daily routine, thus illness, medication prescribed and other treatment modalities (eg massage, aromatherapy) should be understood by the patient. The nurse therefore should assess the appropriateness of the information given to the patient before, during and after the interview or counselling. Touch is one of the important supporting actions a nurse can undertake, and therefore a patient should be greeted with a handshake, if possible, and the nurse should introduce him- or herself by name to take the first step in establishing a trusting relationship with the patient. If possible, talk to the patient. Information given or received by a third party could be distorted. When information, for example about foot care, is given, a pamphlet or other written form is of value to the patient, either directly or through a third party. Explain the reason for the interview or counselling. People listen more attentively and effectively if the reason why they should comply with the given information is known. For example, a diabetic patient who knows that eyesight could be lost if treatment is not complied with is more likely to listen than a patient who does not know about the consequences of non-compliance. After greeting the patient, first establish what the patient knows about the illness or condition. Information given should be based on what the patient needs to know. It should be assessed for accuracy, and any misconceptions should be corrected. Establish any concerns that the patient might have, and address them during the interview or counselling session as this will assist in new information being understood and internalised. The nurse should remember that empathy plays an important role during the interview and counselling. The patient needs to know that the nurse understands perceived or verbalised feelings. This communication of care will strengthen the relationship between the patient and the nurse. Compliance with recommended actions will be greater if they do not conflict with the daily routine of the patient. For example, recommending an action that requires walking 5 km every day when the patient leaves home at 5 am and returns at 9 pm will lead to non-compliance. Make sure that any advice can be part of the daily routine of the patient. Tell the patient what to expect from the actions taken and for how long these actions should be carried out, such as taking the correct medication for the period prescribed until the infection is cleared.

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Feedback from the patient gives an indication of what the patient has understood from the interview or counselling session. Allow the patient to ask questions regarding concerns. Sometimes questions might arise that were not apparent when the interview or counselling started. Use the correct terminology when talking to patients, but make sure that all unfamiliar concepts are explained – for example, hypertension is often referred to as ‘high blood’ by the layperson. Maintain control of the interview or counselling by being prepared, taking the concentration span of the patient into account, and making sure the interview/ counselling is an interactive process. The information needs to be organised to prevent confusion. For example, when giving advice about foot care, do not include information about diet. The nurse applies life skills during the interview or counselling session with the patient. Such a session provides information, and affords the nurse the opportunity of building and maintaining a trusting relationship with the patient. The purpose is to accompany the patient towards problem solving, either physically, emotionally, socially or spiritually. Interviewing techniques take into account culture, language, interpersonal skills, communication skills and observation.

Conclusion Life skills are an important aspect for personal and professional attributes. Competence in these skills will ensure that nurses are well rounded and able to manage and balance the time they have between their professional and personal development; and make sound decisions in resolving problems in their life and at work. As life and the nursing practice pose challenges, nurses, through the acquisition of life skills are able to be introspective and look at themselves in a way that other people perceive them. They are able to behave in a manner that is mature, communicate meaningfully and empathise with their patients, as well as handle stressful situations which are inherent in their daily activities.

Suggested activities for students Activity 16.1 Write a journal describing your personal and professional growth, including the development of self-knowledge and self-understanding, the problems you have experienced, and the techniques you used to solve them on your journey of selfdevelopment.

Activity 16.2 Exercise techniques to promote assertive behaviour and apply them in interpersonal and professional relationships.

Activity 16.3 Practise techniques to promote conflict management and apply them in interpersonal and professional relationships.

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section

2

Chapter 17  Oxygen need

General nursing science

The approach to this section of the book is the needs approach, which is a holistic approach to nursing that covers physiological, psychological, spiritual and social needs. Human needs are the elements required for survival and for normal mental and physical health. The physical requirements for human survival are referred to as physiological needs, which include the need to breathe normally (for oxygen); to eat and drink adequately (for nutrition and fluid balance); to eliminate waste products; to move and maintain desirable postures (for mobility and exercises); to maintain homeostasis (for body temperature, fluid, electrolytes and acid–base balance); to rest and sleep; and to keep the body clean and well groomed. The human body cannot function adequately and disease will occur if the physiological requirements are not met. • Physiological needs are regarded as the most important and should therefore be met first – before psychological, spiritual and social needs. • Psychological needs relate to the person’s ability to organise thought in a logical manner, solve problems and function adequately in relation to the environment, other individuals and the community. • Spiritual needs are not the same as religious needs. The spiritual dimension of human nature encompasses the need to find meaning in life and unvolves a relationship with the Supreme Being – something bigger than the self. This need is based on defining life values and belief systems. • Social needs relate mainly to relationships with others, based on the manner in which one carries oneself in society, because humans are social beings. They have a body image, a self-concept and self-esteem, and therefore need to be recognised, respected and accepted.

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Oxygen need

Learning objectives On completion of this chapter, the student should be able to do the following: • Describe the factors influencing respiration. • Differentiate between breathing and respiration. • Identify the common causes of inadequate oxygenation of cells and tissues. • Describe the assessment of a patient with unmet oxygenation needs. • List common problems related to unmet oxygenation needs. • Describe the signs and symptoms of common problems related to unmet oxygen needs. • Formulate nursing diagnoses related to unmet oxygenation needs. • Care for patient with common disorders related to unmet oxygenation needs. • Identify indications for oxygen therapy. • List various methods of administration of oxygen. • Describe the management of a patient on oxygen therapy.

Key concepts and terminology Anaerobic respiration: A process in which cellular respiration occurs in the absence of oxygen. Breathing: A process of taking in oxygen from the external environment during inhalation and releasing carbon dioxide during exhalation. Cellular respiration: A process utilised by cells to obtain energy from the oxidation of organic compounds accompanied by the consumption of oxygen and the release of carbon dioxide. Cough: Sudden, forcible, noisy expulsion of air from the lungs in an effort to clear the airways from mucus or other extraneous matter. Cyanosis: Bluish discolouration of the skin and the mucous membranes due to lack of oxygen in the blood. Dyspnoea: Difficulty in breathing. Haemoptysis: Coughing up of blood. Hypoxaemia: Low oxygen concentration in the blood. Hypoxia: Low oxygen uptake in the brain.

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Orthopnoea: A sensation of breathlessness in the recumbent position, relieved by sitting or standing.  pH: A measure of the hydrogen ion concentration in body fluids, indicating the acidity or alkalinity of body fluids. Respiration: A metabolic process in which respiratory gases are exchanged in the alveoli, where carbon dioxide is excreted and exhaled, and oxygen is absorbed by the red blood cells. Tachypnoea: Rapid breathing.

Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy and physiology of the cardiovascular system and the respiratory system • Applied biophysics and chemistry.

Medico-legal considerations • By definition, oxygen is a drug, and as such it should be prescribed by a doctor and administered in accordance with medical instructions and precautionary measures. It frequently occurs, however, that a nurse is required to commence oxygen therapy for a distressed patient pending the arrival of a medical practitioner, according to the knowledge and skills of the nurse. When the doctor arrives, the nurse’s initial prescription may be modified. (Many institutions have regulations that limit the percentage of oxygen that may be prescribed by a nurse. Note that this is an institutional requirement and is not based on the scope of practice for nurses.) • The scope of practice for professional nurses directs them to ensure the maintenance of a supply of oxygen to patients. This means that, depending on the knowledge and expertise of the nurse, a spectrum of techniques may be used to achieve this aim, provided that the nurse is competent in those skills, such as: –– opening the airway by positioning the head correctly –– clearing the oropharynx of secretions –– inserting an airway –– endotracheal intubation –– endotracheal suctioning –– administering oxygen using a facemask, ambu-bag, mouth-to-mouth resuscitation and mechanical ventilation.

Key ethical considerations The nursing of patients with respiratory problems frequently presents ethical problems, for example: • The right of a patient in respect of oxygen relates to the patient’s right to life. ➙

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In many instances, the rights of the patient to oxygen (air) may have to be considered in light of the availability of equipment and resources. The nurse has a duty to act as a patient advocate in ensuring that the patient’s physiological need for oxygen is met. • Communication and psychological support are of the utmost importance when nursing a ventilated patient. In this situation, nurses will also be expected to offer support, reassurance and education to the family.

Essential health literacy • Respiratory diseases and problems are commonly found in the community, and chronic respiratory disease is a frequent cause of chronic ill health. The community should be made aware of factors that may lead to respiratory problems, as well as how to recognise respiratory illnesses while they are still at a stage where they may be treated. • Cigarette smoking is a leading cause of lung cancer, as well as other chronic lung diseases such as chronic bronchitis and emphysema. Although legislation limiting the areas where people may smoke has been promulgated and there are restrictions on the sale of cigarettes to minors, the best way to reduce the hazards of smoking is never to start. It is vitally important to make the community aware of the dangers of smoking, and every health worker has an important role to play in this regard. Health workers should not only talk about the dangers of smoking but they should set an example to the community by not smoking themselves, especially not while on duty in a healthcare facility where they will be seen by members of the community. It is also important to work with community leaders, especially educators, to create a culture in which it is unfashionable for teenagers to smoke. Many chronic smokers start smoking in their teenage years because of peer pressure and a reluctance to seem different from the rest of the crowd. Smoking is a known risk factor in many respiratory conditions. If they smoke, patients should be made aware of the dangers and be encouraged to quit. • Air pollution is another leading cause of chronic respiratory problems. Smoke and dust in the air can cause chronic irritation of the airways, leading to asthma and other chronic respiratory problems. Sources of pollution are many, and include industry, as well as the smoke from household fires burning coal or wood. The community should be made aware of the benefits of breathing clean air and of the dangers of pollution. Pollutants may not only irritate the lungs but some industrial effluents contain toxins that may affect other body systems. The community should also be made aware of legislation designed to control pollution and where to get help for problems of pollution. • Braziers and paraffin stoves used for heating or for cooking in closed rooms or huts are also potentially dangerous. Not only may individuals be exposed to possible carbon monoxide poisoning through inadequate ventilation of the hut or room, but coal stoves and paraffin stoves may also give off noxious fumes that irritate the airways, causing chronic inflammation of the lungs. Soot from coal braziers and wood fires may be inhaled into the lungs, causing chronic irritation and inflammation, the so-called ‘hut lung’. Coal braziers and paraffin stoves also frequently cause fires.  ➙

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Where coal braziers and paraffin stoves are used, it is important that the room be adequately ventilated to prevent the build-up of carbon monoxide or of toxic fumes. Where possible, these devices should be used outside in the open where the fumes can dissipate. • In South Africa, pulmonary tuberculosis (TB) is rife and is a leading cause of death and debility in the community, yet TB is potentially curable, especially if it is recognised early and treated at the earliest possible stage. It is important for health workers to teach community members how to recognise TB in themselves or in family members. Projects to teach traditional healers how to recognise TB have also been launched and these have been relatively successful, as many patients will consult a traditional healer first before coming to a Western centre for treatment. The following signs and symptoms are suggestive of TB and should be investigated: –– Any cough that persists for more than three weeks –– Unexplained weight loss –– Unexplained fever, especially at night –– Night sweats –– Coughing up of blood-stained sputum –– Shortness of breath, especially on exertion. • Nurses have an obligation to encourage optimum health by educating their patients, for example telling them that an open flame, including a cigarette, is not allowed around a patient on oxygen therapy as oxygen is inflammable and an explosion may result.

Introduction Oxygen is a basic human need that is essential to sustain life. It plays a vital role in producing the energy necessary for carrying out essential body processes such as cellular respiration and metabolism. Oxygen is found in almost all biomolecules that are important to life, with organic compounds such as carbohydrates containing the largest proportion of oxygen. All fats, fatty acids, amino acids and proteins in the living body contain oxygen. Without a consistent supply of oxygen, people can begin to experience cerebral hypoxia and after as few as five minutes without oxygen, there will be severe brain damage. With insufficient oxygen in the blood, a person feels tired, toxins accumulate and circulation becomes very sluggish, which results in an inadequate amount of oxygen reaching the cells. Inadequate oxygen in the blood is one of the many underlying causes of poor health and disease. The purpose of this chapter is to enable nurses to develop proficiency in the specific skills and techniques used in the assessment of the respiratory system which is responsible for oxygen delivery to tissues and the removal of carbon dioxide from the body. Nurses will be assisted to develop an understanding of the care and management of common clinical problems related to the ineffective function of the respiratory system. They will thus be in a position to develop effective care plans for patients suffering from problems related to unmet oxygen needs (inadequate oxygenation of cells and tissues), including the evaluation of care and the monitoring of patient progress.

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Normal factors influencing respiration The primary function of the respiratory system is to ensure adequate delivery of oxygen to meet tissue requirements and to remove carbon dioxide from the blood. This process involves the organs, nerves and muscles of respiration. The central nervous system, via the respiratory control centre, must be able to regulate the cycle of inspiration and expiration.

The process of breathing The process of breathing is based on the movement of air from areas of high pressure to areas of lower pressure. When we breathe in, the diaphragm and intercostal muscles contract: the diaphragm becomes flattened, which enlarges the superior-inferior diameter of the chest cavity, and the intercostal muscles move the ribs in an upward and outward direction, which enlarges the lateral and antero-posterior diameters of the chest cavity. The air already in the lungs is now at a lower pressure than the pressure of the atmospheric air outside the body, because of the increased size of the chest cavity. Air moves in from the area of higher pressure outside to the area of lower pressure in the thoracic cavity. This is inspiration. During expiration, the process is reversed: the diaphragm and intercostal muscles relax and the chest cavity returns to its normal size. Air in the lungs is now at a slightly higher pressure than the pressure of the atmospheric air outside, and it now moves out, once again moving from an area of higher pressure to one of lower pressure. The rate and depth of breathing depend on the needs of the body for oxygen and the need to excrete carbon dioxide. Factors that influence the rate and depth of breathing include the following: • Age. The respiratory rate at rest tends to decrease with age. • Emotion. Anxiety, anger and excitement all increase the rate and depth of breathing. • Exercise. The rate and depth of breathing are increased during physical exercise. • Rest. The respiratory rate slows at rest and is at its slowest during deep sleep. Respiration Another function of the respiratory system is to ensure a stable internal environment by ensuring the constant delivery of oxygen for cellular metabolic needs, and the removal of carbon dioxide. During respiration, gases are exchanged in the alveoli, where carbon dioxide is excreted and exhaled, and oxygen is absorbed by the red blood cells. In the capillaries, oxygen is released to the tissues, and carbon dioxide is taken up by the red blood cells, to be taken back to the lungs and excreted. The process involved in gas exchange is called diffusion, which refers to the movement of molecules from an area of higher concentration to an area of lower concentration of those molecules.

Causes of inadequate oxygenation of cells and tissues In nursing, one often encounters a patient who is unable to meet the need for oxygen independently due to pathological conditions or injury, or as a result of therapeutic interventions. Some of the factors that prevent the body from inhaling oxygen are the following: • Environmental risks such as air pollution (the presence of high amounts of smoke, fumes and gases) 305

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• • • •

Carbon monoxide poisoning High altitudes Medical conditions such as cardiac arrest, drowning, lung infections, etc Injury to the chest wall and lungs.

Nursing assessment of respiratory function A comprehensive assessment of respiratory function includes a history from the patient, a physical examination and diagnostic testing. This information is used to compile a database, to formulate a diagnosis and to determine therapeutic interventions.

Patient history The first step of the nursing assessment is to take a detailed patient history, provided that the condition of the patient allows it. The nurse takes a general history from the patient, but thereafter it is important to focus on obtaining a history of symptoms related to respiratory problems. General history

From the history, the nurse obtains a subjective review of symptoms related to the patient’s present and past health condition or illness. Included in this aspect are the demographic details of the patient pertaining to personal identification. These include name, address, date of birth, age, marital status, nationality, occupation, and source of and reason for the referral. The chief complaint is the actual reason why the patient sought healthcare. It is important that the nurse allows the patient to express the symptoms in his or her own words. The most common manifestations of respiratory dysfunction experienced by patients are the following: • Dyspnoea • Shortness of breath • Sputum production • Cough • Chest pain. The nurse should obtain the course of events or chronological description of each of the symptoms mentioned. The nurse should focus on the circumstances surrounding the onset of the symptoms (eg time, setting, frequency and duration), the severity of the symptoms, and any aggravating or alleviating factors. Asking the patient to recall the sequence of the symptoms will enable the nurse to associate these with certain disease conditions. For example, a cough followed by pyrexia and chest pain of acute onset is the classic description of pneumonia. Once the patient’s current problem has been elucidated, it is important that the nurse reviews the patient’s health prior to onset of the current problem. It is essential to inquire about childhood diseases; growth, development and immunisations; previous hospitalisations, for example surgery, injuries, accidents and major illness; habits and current medication. Finally, the nurse must inquire about allergies and family disease history (cystic fibrosis, for example, is a congenital condition, and asthma is generally familial – that is, seen in family members). A brief inquiry into the social and environmental background of the patient is important to elicit any information that 306

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might contribute to the patient’s current condition. These may include recent travel, poor living conditions, self-neglect, and any other events that might impact on health.

Questions that can be used as a guideline to obtain the history • Do you have problems breathing? • Can you describe the circumstances when this occurs? • What do you do to relieve it? • Can you describe your cough? • When does it occur? • Does the cough produce any sputum? • If so, how much? • Is it thick or thin? • What colour is it? • Is it blood stained? • Do you have pain associated with breathing? • Where is it located? • How would you describe the pain? • Is it continuous, or when does it occur? At inspiration or expiration?

In summary, this section of the assessment enables the nurse to identify the degree of respiratory discomfort in the form of the symptoms, the course of events, the pattern of the disease, contributing or alleviating factors, a health history and any underlying risk factors that might contribute or complicate the current condition.

Physical examination The physical examination is performed to provide objective data for the respiratory assessment, and includes the clinical signs that can be seen, felt or touched, and heard by the nurse. The traditional techniques of inspection, palpation, percussion and auscultation are used. Inspection

• On inspection, the nurse is able to elicit information about the level of consciousness, breathing pattern, chest wall movement, shape of the chest and observation of the skin for scars, masses, lesions, colour, naevi and irritations. • The nurse should check the patient for neurological signs of hypoxia – that is, restlessness, drowsiness, irritability, decreased level of consciousness and cardiovascular changes which may indicate the body’s attempts to compensate. These changes include tachycardia, hypertension and peripheral vasoconstriction. • Observation of the patient’s spontaneous respiration is undertaken for a full minute to determine the rate, depth and rhythm of breathing. Observation of the chest wall movement for symmetry is best performed from the foot of the bed. Asymmetrical expansion may, for example, indicate a pneumothorax, endotracheal intubation of the right main bronchus, consolidation, pneumonectomy, etc. • The anterior/posterior diameter of the chest is observed, noting that the transverse diameter should be twice that of the anterior/posterior diameter. Abnormalities that 307

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may be identified include a barrel chest, possibly indicating chronic obstructive airway disease; a pigeon chest, as seen with emphysema; or a funnel chest, which may indicate rickets. • It is important to note whether the patient is using the accessory muscles of respiration as this is suggestive of increased work of breathing, eg with poor lung compliance. • The skin and mucous membranes are observed for cyanosis. It is important to distinguish between central and peripheral cyanosis. Central cyanosis occurs as the result of hypoxia and is seen on mucous membranes, chest and trunk, whereas peripheral cyanosis may result not only from hypoxia but also from poor circulation and vasoconstriction, and is visible on fingertips, earlobes and toes. • Finally, the nurse should inspect the patient’s fingers for clubbing, which is associated with chronic hypoxia, but can be due to cardiac disease. Clubbing can be congenital in some cases.

Nursing alert! The nurse should not rely only on visual inspection of the rate and depth of a patient’s respiratory excursions to determine the adequacy of ventilation. Respiratory excursions may appear normal or exaggerated. Percussion

Percussion is the method of examination providing information as to whether the underlying tissue is solid, fluid filled or air filled. To perform the technique, the middle finger is placed flat on the patient’s chest between two ribs. With the tip of the middle finger of the other hand, tap the first joint of the finger lying on the chest using a small movement of the wrist. It is important to note that the technique requires only light pressure on the chest in order to avoid distorting the percussion sounds. The chest is percussed anteriorly and posteriorly, moving from the upper to the lower chest while comparing the sounds on each side of the chest. Normal percussion sounds of the chest are described as follows: • Resonance, which is a hollow, low-pitched sound heard with normal air-filled lungs • Dullness, which is a thudding, muffled, soft and short sound heard over fluid-filled organs such as the heart or liver • Flatness, which is an extremely dull sound heard over dense, airless tissues such as the sternum or muscle • Tympany, which is a drum-like sound – that is, loud and high pitched, heard over a completely air-filled stomach • Hyper-resonance, which is a musical sound, louder but with a lower pitch than resonance. Abnormal percussion sounds include the following: • Flatness, heard over the lungs where fluid or mucus has replaced air, for example atelectasis 308

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• Dullness over the lungs, indicating airless tissue, for example with a pleural effusion • Tympany, heard over the lungs signifying increased air volume, for example large pneumothorax • Hyper-resonance, heard over the lungs, which is a booming sound that may be heard with emphysema or pneumothorax where there is increased air in the thorax. 1

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Figure 17.1  Positions for percussing and auscultating the thorax Palpation

Palpation provides information about thoracic excursion, elicits areas of swelling or tenderness, and identifies tactile vocal fremitus (vibrations due to secretions). It also enables the nurse to obtain information about the skin, such as sensitivity, moisture, elasticity and temperature. To check for symmetrical expansion of the upper chest, the nurse places his or her palms on either side of the chest, with the fingers resting on the patient’s shoulders. 309

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The thumbs are extended medially until they meet. As the patient inhales or exhales, the nurse will observe the movement of his or her thumbs, which should move simultaneously, and equally towards and away from the midline with expiration and inspiration respectively. Unilateral chest lag may indicate thickening pleura, atelectasis and obstruction of a major bronchus or pneumothorax. The nurse then examines the mid-chest, by placing his or her hands on the sides of the patient’s chest with the thumbs resting on the level of the sixth rib and extending towards each other. The examination is then repeated on the lower chest.

Figure 17.2  Palpation for symmetrical expansion of the chest

Figure 17.3  Palpation for vocal fremitus

Tactile fremitus (vibration that can be felt) is defined as a vibration felt by the hand when placed on a part of the body, especially when the patient is speaking or coughing. This is evaluated with the nurse positioning his or her hands on either side of the upper chest with the palms flat against the chest, and the patient repeating the words ‘ninetynine’. The nurse will follow the sequence indicated in percussion, and expect to feel fremitus in the upper chest, close to the bronchi. However, there should be little or no fremitus felt in the lower chest. In the upper chest, the nurse should feel vibrations of equal intensity on either side of the chest. Lesser intensity on one side may indicate emphysema, pneumothorax or pleural effusion. Auscultation

Auscultation enables the nurse to identify breath sounds. The technique involves the use of a stethoscope to listen to the movement of air and to compare the sounds on each side of the chest. The stethoscope diaphragm is placed firmly against the patient’s skin on the chest. The same sequence is followed as for percussion, moving anteriorly, posteriorly and laterally over the entire chest. • Normal breath sounds are described as follows: –– Vesicular – high pitched and loud on inspiration, and low pitched and soft on expiration –– Bronchial or tracheal – high pitched, loud, harsh and hollow –– Broncho-vesicular – medium to high pitched or muffled. 310

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• Normal vesicular sounds should be heard over the peripheral lung fields. Diminished vesicular sounds could indicate emphysema or early pneumonia. Normal bronchial sounds should be heard over the trachea or mainstem bronchus. • Abnormal bronchial sounds over the peripheral lung fields may indicate atelectasis or consolidation. • Normal broncho-vesicular sounds should be heard over the large airways, on either side of the sternum and between the scapulae. • Abnormal broncho-vesicular sounds over peripheral lung fields may indicate consolidation. • Abnormal breath sounds are described as wheezing, stridor, rhonchi and crackles: –– Wheezing is a whistling sound heard on inspiration and/or expiration, and may be either high or low pitched. Upper airway obstruction usually results in an inspiratory wheeze, whereas lower airway obstruction usually results in an expiratory wheeze. –– Stridor is a high-pitched crowing sound heard over the upper airways, and is due to partial obstruction such as laryngeal oedema or obstruction by a foreign body. –– Rhonchi are coarse, continuous, low-pitched, sonorous or rattling sounds produced by excess mucus or fluid occurring as a result of diseases that cause inflammation, for example pneumonia, bronchitis or pulmonary oedema. –– Crackles are discontinuous, explosive bubbling sounds of short duration that signify fluid retention in the small airways, for example pulmonary oedema, atelectasis and retention of mucus. • Retained secretions result in a coarse, low-pitched, continuous rattling sound as air flows through the airways over the secretions.

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Figure 17.4  Auscultation sequence of the thorax

Nursing implications • Instances in which respiration need not be observed are minimal, as most illnesses have some effect on breathing. As a rule, therefore, the rate and character of breathing should always be observed. 311

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• To fully observe the character of breathing, the patient should be watched for a full minute – and longer if breathing is difficult or irregular. • Prescribed oxygen therapy should be continuous. If, for some reason, an oxygen mask must be removed (eg to allow the patient to eat), nasal cannula should be used to continue the supply of oxygen. • Alarms on pulse oximeters and ventilators should never be switched off. • A machine with an alarm that is going off frequently must be carefully investigated and the reason must be found and rectified. • Faulty equipment should be replaced or repaired. • Ventilated patients should never be left unattended, as accidental disconnection may be fatal. The nurse should be able to see the patient at all times.

Diagnostic tests The most commonly used basic diagnostic tests to assess the adequacy of pulmonary function are chest X-rays, pulse oximetry and arterial blood gas monitoring. Sputum culture is not routine unless an infection is suspected, but this depends on the institution. More advanced tests include lung scans, bronchoscopy, pulmonary angiography, and skin tests for allergies and TB. Sputum culture

Sputum is collected in a sterile container and sent to the laboratory for microscopy and culture. Normally a fresh morning specimen is collected before the patient has had anything to eat or drink, and sent to the lab for examination. Physical examination of sputum

It is also important for the nurse to observe the characteristics of the sputum as this may provide important information regarding the condition of the patient: • Normal sputum is clear or a translucent white, with no odour. • Sputum that is thick and difficult to expectorate may be an indication that the patient is dehydrated. • Yellowish-green sputum with a foul or musty odour is suggestive of infection. • Sputum that is bloodstained indicates inflammation of the airways. • Bright red blood in the sputum is a sign of bleeding in the respiratory tract (called haemoptysis) and must be thoroughly investigated. Pulse oximetry

Non-invasive pulse oximetry provides an indirect measure of arterial oxygen saturation, using red and infrared light to detect the percentage of oxygen that is bound to haemoglobin. A sensor is usually attached to the patient’s finger, toe or earlobe. Nasal sensors and sensors that attach to the forehead are also available, but not in general use. Heart rate, as well as oxygen saturation, can be measured via these sensors. Certain disease conditions, such as carbon monoxide poisoning, may interfere with the accuracy and functioning of the sensor. The normal oxygen saturation range is above 95%, with a value of 90% being the lowest acceptable figure. An oxygen saturation level of less than 90% indicates a need for oxygen therapy and further investigation. Pulse oximetry is simple and easy to use at the bedside – it is painless and convenient, and results are readily available. 312

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Chest radiography

The chest X-ray is the most commonly used diagnostic tool in respiratory conditions, especially when assessing the contents of the chest cavity. The chest X-ray can be used to detect alterations in lung pathology, and can also be used to determine the appropriate treatment or evaluate the effectiveness of treatment, provide information about the position of tubes and catheters, and monitor the progression of lung disease. Bronchoscopy

This test allows for the direct visualisation of the larynx, trachea and large airways by means of a flexible fibre optic tube, or bronchoscope. It provides information on the trachea and bronchi, and enables tissue sampling for analysis and the removal of large mucous plugs or other aspirated objects that could be obstructing the airway. Lung scan

The lungs are scanned by measuring the gamma radiation emitted from the chest following the intravenous injection of radioactive material. A lung scan provides information about the distribution of ventilation and perfusion, and the effect of disease processes on these functions. The major clinical indication for a lung scan is pulmonary embolism. The technique of lung scanning is performed in two stages: a perfusion scan followed by a ventilation scan. The two scans are then compared, matching ventilation to perfusion. After a pulmonary embolism, the perfusion scan will show abnormalities, whereas the ventilation scan will be normal. Clavicle Trachea

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Hilium of the lung with blood vessels Right cardiac border Left cardiac border

Figure 17.5  Key features of a typical chest X-ray 313

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Pulmonary angiography

This is a specialised radiographic investigation that is usually carried out to investigate thrombo-embolic lung disease, such as pulmonary embolism. Contrast medium is injected into the pulmonary artery or, in the case of a selective angiogram, into one of its branches. This technique is invasive and the decision to use it must be made cautiously, especially in patients who are critically ill.

Common respiratory problems Cough Coughing is the most common symptom of broncho-pulmonary disease. It is a protective reflex used to clear the airways of excess mucus or foreign substances. Causes

Coughing may be voluntary or involuntary, and is due to irritation of the lining of the respiratory tract. Stimulation of cough receptors may be due to the following: • Inflammation, for example infection or allergy • Mechanical pressure on the airways, for example tumours, aneurysm • Chemical factors, for example inhaled impurities such as smoke, fumes and gases • Thermal factors, for example the sudden inhalation of very cold or very hot air, which may cause coughing or an asthmatic attack. Nursing assessment

The nurse should first obtain a history from the patient regarding allergies, asthma, current respiratory infections, smoking and/or exposure to environmental irritants such as dust, fumes or gases. The patient should be asked to describe the onset of the cough: the nurse should ascertain whether the onset was acute (over hours or days) as with a respiratory tract infection, or chronic (over weeks or months) as with TB or bronchogenic carcinoma. The nature of the cough and the time of day at which it is most noticeable or troublesome should be ascertained. A cough on waking in the morning may be suggestive of chronic bronchitis or bronchiectasis. A cough later in the day may be related to exposure to inhaled irritants. Paroxysmal coughing, especially at night, is often related to left-sided cardiac failure or to asthma. Coughing when lying flat may be related to a chronic postnasal drip, bronchiectasis or gastro-oesophageal reflux with aspiration. Coughing following eating or drinking may be suggestive of neuromuscular disease or to aspiration. The nurse also needs to determine whether the cough is productive or not, and whether it is forceful enough to clear the airway of secretions and foreign substances. A weak cough will not clear the airway and is therefore ineffective. If the cough is productive, the nature of the secretions produced must be determined. The sound of the cough should be assessed. A barking cough may be suggestive of laryngo-tracheo-bronchitis or influenza, and a hacking cough may indicate a viral infection or it may be associated with bronchogenic carcinoma. Hoarseness may be suggestive of laryngitis, wheezing is usually related to asthma, and inspiratory stridor could be suggestive of laryngeal oedema or epiglottitis. 314

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Nursing interventions

The nurse should be able to help the patient with coughing and expectoration. Vibration of the lower chest during expiration may help to loosen secretions. Assistance with coughing and expectoration is indicated for patients who have excessive bronchial secretions, and who are unable to cough effectively to clear these secretions. Assistance with coughing is also indicated post surgery to help prevent atelectasis and pneumonia, and in patients who have respiratory disease. Measures to loosen secretions are mandatory for patients who have an artificial airway in situ, as the tube prevents effective coughing. Postural drainage. This technique that makes use of gravity to assist with the drainage of secretions from various regions of the lung to the larger bronchi, from where they can be coughed up or removed by suctioning. The basic principle involves placing the affected area of the lung uppermost:

Figure 17.6  Vibration of the lower chest to assist in coughing • Sitting upright allows drainage of the upper lung fields and aids forceful coughing. • Lying on the right or the left side with the hips elevated on cushions or pillows helps to drain the lower lobes of the lung. • Lying on the back with the hips elevated on cushions or pillows helps to drain the anterior areas as well as the lower segments of the lung. • Lying face downwards with the hips elevated on cushions or pillows helps to drain the posterior areas of the lower lobes. • Adequate hydration of the patient is essential to prevent the drying out of secretions. Dry secretions may form thick mucus plugs that may obstruct or block off entire areas of the lung. Steam inhalations and saline nebulisers may also help to loosen secretions and keep them moist. • Adequate nutrition of the patient is always essential. 315

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• Patients who are weak should be helped to sit up in order to cough. Supporting the chest with the hands or a soft pillow will also help the patient to cough. • Post-operative patients are often reluctant to cough because of pain from the surgical wound. Adequate pain relief is essential for these patients. It is also helpful to sit these patients up and to support the chest and the operated site in order to help them cough. • Good oral hygiene should be maintained. Patients who are coughing up foulsmelling sputum often have a bad taste in their mouths, and oral hygiene is helpful to them. • Specific treatment may include expectorants, mucolytic agents, nebulisers and metered dose inhalers. All of these treatments should be given as prescribed.

Prone and head down to drain lower lobes

Sitting upright in high Fowler's to drain upper lobes

Flat, on right or left side to drain middle lobes

Figure 17.7 Positions for postural drainage 316

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Chronic cough. The typical cough associated with flu should settle in 10 days to two weeks. Any cough that persists for longer than three weeks should be treated. The patient should be seen at a community clinic, hospital outpatient department or by his or her own doctor. A persistent cough may be indicative of a potentially serious respiratory problem. Sputum. In normal respiratory function, up to 100 ml of clear sputum is produced by the respiratory tract each day. This sputum is moved upward by the action of the cilia and it is usually swallowed unnoticed. An increase in the amount of sputum, or a change in its colour or consistency, is usually indicative of pulmonary pathology. Nursing assessment

The nurse must evaluate the colour, consistency, amount, odour and presence of distinguishing matter such as pus, blood or mucous plugs in the sputum. This evaluation often gives a clue as to the nature of the underlying pathology. A history should be taken from the patient, but the nurse should remember that such a history might be inaccurate due to the social stigma attached to sputum production. Collection and inspection of the sputum is usually necessary for an accurate assessment. The following factors should be noted: • The time of day at which the sputum is produced; for example, increased production on waking in the morning indicates that secretions have accumulated overnight, and is seen in bronchitis. • The odour of the sputum may vary from odourless to foul smelling, the latter being common with bronchiectasis and lung abscesses. • The consistency may be frothy, thin or watery, thick, viscous or tenacious (very sticky). • The amount of sputum is usually described as being scanty, moderate or copious (large amounts). • Mucoid sputum is thin, clear and viscid. It is caused by an over-secretion of bronchial mucus such as occurs in bronchial asthma. • Mucopurulent sputum is usually thick and viscid, and may be offensive or inoffensive and coloured, as in the case of cystic fibrosis. • Purulent sputum is usually coloured, offensive and copious. Rusty-coloured sputum may be suggestive of pneumococcal pneumonia, and yellow or green sputum is often related to pseudomonas infection or bronchiectasis. • Greenish grey sputum is often associated with advanced TB, and black sputum is indicative of smoke or coal dust inhalation. • Frothy sputum, often pinkish in colour, may be seen with pulmonary oedema. • Sputum streaked with blood, or frank blood, may be seen in conditions such as pulmonary infarction or embolism. Nursing interventions

• Administer medications and treatments as prescribed by the medical practitioner, which could include expectorants, mucolytic agents, antibiotics for infection and anti-tubercular agents. • Ensure adequate hydration of the patient to prevent secretions from drying out.

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• Assist the patient while coughing. He or she should sit up and the chest should be supported while coughing. • Use postural drainage and physiotherapy to help the patient cough up secretions. • Collect sputum for microscopy, culture and sensitivity, and assess and record the quantity, colour, consistency and odour.

Disposal of sputum at home • Sputum is often highly infectious and should not be left lying around the house, as the entire family may then become infected. • Encourage the patient to cough into a tissue and to place it in a separate wastepaper bin or plastic bag (supermarket packets make good containers for disposal as the plastic keeps moisture in). Tissues are more hygienic than handkerchiefs because they can be thrown away. • Used tissues can be flushed down the toilet or sealed in a plastic packet and placed in the outside rubbish bin. If a flush toilet or rubbish collection system is not available, used tissues should be burnt. • If handkerchiefs are used, they should be washed daily after soaking in warm water to which a little bicarbonate of soda has been added. The bicarbonate of soda helps to dissolve the secretions that have adhered to the handkerchief. If possible, several handkerchiefs should be available to allow for frequent changes. • The soiled water that has been used to soak the handkerchiefs should be thrown down the toilet or into a ditch specifically meant for the disposal of soiled water.

Dyspnoea The word ‘dyspnoea’ means difficult breathing. Dyspnoea is said to occur when a patient becomes unduly short of breath on minimal physical exertion. Dyspnoea may be acute or chronic, recurrent, paroxysmal or progressive. The patient may experience difficulty with either inspiration or expiration. Inspiratory dyspnoea is usually associated with problems of the larger airways, such as croup, and expiratory dyspnoea is usually associated with problems of the smaller, more distal airways, such as asthma. Causes

Dyspnoea may be due to cardiac or pulmonary disease. Shortness of breath associated with pulmonary disease is due to a change in lung compliance and/or an increase in airways resistance, both of which will cause the work of breathing to be increased. Sudden onset of dyspnoea occurs with conditions such as pulmonary embolism and pneumothorax. • Orthopnoea is the term used to describe dyspnoea when the patient is short of breath when lying down and can only breathe with relative ease when in the upright position. The cause of orthopnoea may be cardiogenic pulmonary congestion, or chronic pulmonary disease, such as in chronic obstructive pulmonary disease (COPD). • Paroxysmal nocturnal dyspnoea is the sudden onset of dyspnoea occurring within a few hours of the patient lying down at night. It is usually accompanied by coughing and is relieved when the patient sits upright. 318

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• Platypnoea is dyspnoea while in the upright position and can be seen in patients with COPD and sometimes following pneumonectomy. Nursing assessment

Nursing assessment includes taking a history from the patient regarding the factors that trigger the patient’s dyspnoea, for example does it occur when lying down or on exertion? The duration and severity of the dyspnoea should also be determined. Noting the patient’s ability to talk during the attack can assess the severity. The respiratory rate, heart rate and any accompanying symptoms such as wheezing, stridor and coughing must be noted. The nurse should also note whether the onset of dyspnoea is sudden or gradual. The impact of dyspnoea on the activities of daily living of the patient (walking, eating, dressing, sleeping) should also be assessed. Nursing intervention

• Treat the cause by alleviating or removing the triggering factors, such as dry air or dust. • Place the patient in a comfortable position, usually sitting upright to facilitate breathing. • The patient should be dressed in loose-fitting clothes, especially around the chest and abdomen. • Make sure the area is well ventilated to allow for free circulation of air. • Administer oxygen therapy, nebulisers and inhalers as prescribed. • Regularly assess the respiratory status of the patient until breathing has returned to normal. • Reassure the patient and provide psychological support.

Coping with an acute dyspnoeic attack at home Any patient with a chronic respiratory disease such as asthma or emphysema may suffer an acute attack of dyspnoea while at home, and this can be extremely frightening for the family of the patient. • Get the patient to stop whatever he or she is doing and to sit and rest. Reducing the activity level reduces the body’s oxygen requirements and may alleviate the dyspnoea. • Remove the patient from anything that could aggravate the attack. • Give a steam inhalation if the patient has stridor or is having difficulty in coughing up thick secretions. Place boiling water from a kettle in a bowl and let the patient sit with his or her head over the steaming bowl and breathe in the steam. • Let the patient take a metered dose from an aerosol inhaler if one is available. Get the patient to rest quietly while waiting for the aerosol to take effect. Some bronchodilator inhalers are available over the counter at chemists and can be purchased for use in the case of a dyspnoeic attack. If, after half an hour, the patient is still severely dyspnoeic, a second dose from the inhaler may be taken. If the attack does not subside after two doses have been taken, the patient should immediately be taken to the nearest casualty, doctor or community clinic. • Let the patient take a dose of his or her bronchodilator inhaler in the case of a known asthmatic, and then have the patient taken to the casualty or clinic immediately, as a sudden asthma attack can rapidly become life threatening.

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Haemoptysis Haemoptysis is the coughing up of blood or blood-stained secretions from the respiratory tract. A massive haemoptysis is defined as being the coughing up of more than 400 ml of blood within three hours, or more than 600 ml within 24 hours. Massive haemoptysis constitutes a medical emergency and is associated with a high mortality. Causes

Sputum streaked with blood is associated with conditions such as pulmonary embolism, pneumonia and bronchitis. Frank bleeding from the lungs is seen in conditions such as chest trauma, pulmonary TB and carcinoma of the lungs. Nursing assessment

The history taken from the patient should explore the use of anticoagulants and the presence of known cardiovascular and/or pulmonary conditions. Haemoptysis must be differentiated from haematemesis, which is the vomiting of blood. In the case of haematemesis, the blood is usually dark in colour, acid in pH and is often associated with nausea and abdominal pain, whereas with haemoptysis the blood is usually bright red, alkaline in pH and may be associated with dyspnoea, chest pain and other abnormal sensations within the chest. Nursing interventions

• Place the patient at bed rest, preferably on the affected side (if known) to prevent blood from flowing into the unaffected lung. • Deal with the patient’s fear and apprehension in a calm and supportive manner, as profuse haemorrhage may be life threatening. • Establish intravenous access and take blood specimens for cross-matching if necessary. • Administer oxygen therapy as required. • Record the quantity, colour and character of the blood, and report after inspection. • Keep emergency equipment that includes a laryngoscope and endotracheal tube in readiness. • Prepare the patient for surgical intervention if necessary.

Cyanosis Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from a lack of oxygen in the blood. Cyanosis may be central or peripheral, and it is not seen until at least 5 gm of haemoglobin per 100 ml of blood is deoxygenated. Cyanosis can be a misleading sign as it increases with the amount of haemoglobin present. Patients with high haemoglobin levels, as in polycythaemia, may appear cyanotic while they have a relatively normal blood oxygen level, whereas patients with low haemoglobin levels, as in anaemia, may never appear cyanotic even when they have a very low blood oxygen level. Cyanosis may be an indication of cardiac as well as pulmonary disease. Acute respiratory failure Acute respiratory failure is said to have occurred when the tissues are not receiving adequate oxygen to meet their needs. The carbon dioxide that is produced by cellular 320

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metabolism may not be adequately removed, although in some patients the respiratory rate remains adequate to remove the carbon dioxide and the patient presents with hypoxia without hypercapnia. In other patients, the carbon dioxide is not adequately removed, and the patient is both hypoxic and hypercapnic. Respiratory failure or hypoxaemia is specifically defined according to the patient’s blood gases – that is, a paO2 of 50 mmHg or less and a paCO2 of 50 mmHg or more with the patient at rest, breathing room air. Respiratory failure is also said to be present if the patient has a paO2 of 60 mmHg or less while breathing 50% oxygen. Acute respiratory failure is a life-threatening situation, and to prevent permanent brain damage, disability or death, it must be recognised in good time and treated appropriately. In addition to the characteristic blood gas picture, other clinical manifestations include the following: • Dyspnoea, tachypnoea, use of accessory muscles of respiration and cyanosis. Neurological manifestations due to a lack of oxygen supply to the brain include headache, restlessness, agitation, confusion, decreased level of consciousness and coma. • Cardiovascular manifestations include tachycardia, raised blood pressure, peripheral vasoconstriction and sweating. If the problem is not treated, circulatory collapse may occur, indicated by decreased blood pressure, dysrhythmias and ischaemic chest pain with poor peripheral perfusion. Causes

Failure to ventilate the lungs, failure to oxygenate, or both, leading to hypoxaemia and/or hypercapnia, may cause acute respiratory failure. Causes of hypoventilation include depression of the respiratory centre (eg with drugs), airway obstruction and neuromuscular disease. Causes of failure to oxygenate include the following: • Ventilation/perfusion mismatch. This could mean that ventilation is adequate but perfusion to the lungs is poor, as in pulmonary embolism. The converse may also occur, where perfusion is adequate, but ventilation is poor, as in asthma, COPD and pulmonary oedema. • Diffusion impairment means that the movement of oxygen from the atmosphere to the bloodstream is impaired, leading to hypoxaemia. Diffusion defects are far more likely to affect pO2 than pCO2 because carbon dioxide is 20 times more diffusible than oxygen. Conditions that may lead to a diffusion defect include removal of part of the lung (partial pneumonectomy), pulmonary oedema and acute respiratory distress syndrome. • Increased carbon dioxide production is a rare cause of hypercapnia, but may be seen with an increased metabolic rate as in hyperthyroidism, and when large amounts of carbohydrate are administered, such as in parenteral nutrition regimes. Management

The goal of treatment is to treat the cause and to support respiratory function: • Positioning the patient appropriately should ensure an adequate patent airway. It may be necessary to clear the airway of secretions by suctioning. The insertion of

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•

• • • •

•

an artificial airway, such as an oropharyngeal airway or an endotracheal tube, may be necessary. Supplementary oxygen should be administered using a facemask, continuous positive airways pressure (CPAP) or mechanical ventilation as indicated by the condition of the patient. Using bronchodilator drugs as prescribed relieves bronchospasm. Excess secretions should be removed by a combination of physiotherapy, postural drainage and suctioning. Arterial blood gases should be estimated regularly to monitor a patient’s progress. Fluid, electrolyte and acid-base status should be monitored and maintained at optimum levels – that is, as close to normal as possible – by administering fluids and/or electrolytes as indicated. An adequate cardiac output is essential to ensure that oxygen is adequately circulated to all parts of the body. Adequate hydration must be maintained by giving adequate fluids. It may be necessary to support the circulation by administering inotropic agents such as dobutamine (Dobutrex) or adrenaline.

Oxygen therapy Oxygen therapy involves the delivery of supplementary oxygen to a patient to prevent or relieve hypoxaemia. Ambient or room air contains 21% oxygen and therefore oxygen therapy involves the delivery of more than 21% oxygen.

General principles of oxygen therapy • Oxygen is a drug, and should be administered with the same care as any other drug. As with all drugs, oxygen also has a safe range, adverse physiological manifestations, and toxic effects associated with high dosages and prolonged use. • Oxygen is prescribed in litres per minute (l/min), as a concentration (%), or as a fraction of inspired oxygen (FiO2). • Central to the effect of the therapy is a patient with a patent airway. The nurse must pay special attention to the maintenance of a patent airway, and position the patient to facilitate ventilation and oxygenation, for example a high Fowler’s position or supported upright with pillows. Where a high Fowler’s position is contraindicated, as with spinal injuries, an artificial airway can be used to maintain patency. • The effectiveness of therapy is dependent on patient co-operation and an effective ventilation pattern. The nurse must ensure patient co-operation by explaining the reasons why the oxygen therapy is necessary. The patient must be carefully monitored to ensure that the oxygen is used continuously and not abruptly discontinued, but weaned as the pathology necessitating its administration is reversed or corrected. A patient receiving oxygen via a facemask should have the mask replaced with a nasal cannula when eating, brushing teeth, etc. • Effective monitoring of the respiratory system is crucial to determine the effect of the therapy. The patient must be assessed at regular intervals to monitor the effect of oxygen therapy on tissue oxygenation and not simply rely on the numbers from the arterial blood gas or pulse oximetry. ➙

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• Successful administration of oxygen is dependent on an understanding of the functioning of the delivery system. The nurse must understand that low-flow delivery systems do not provide all the inspired gas to the patient as room air is also entrained. However, the high-flow systems allow the patient to breathe only the gas supplied by the system. • When using the manual resuscitation bag to deliver oxygen and positive pressure ventilation, an effective seal must be maintained if a mask is being used to ensure adequate ventilation and oxygen delivery to the patient. • Should the upper airway be bypassed – that is, by means of a tracheostomy or endotracheal tube – appropriate airway humidification must be ensured during oxygen therapy. • Oxygen is a combustible gas. The nurse must ensure that the safety of the patient and those in close proximity is not jeopardised by exposing the oxygen to a flame. ‘Oxygen in progress’ and ‘no smoking’ signs must be visibly displayed. • The equipment necessary to deliver oxygen to a spontaneously breathing patient includes an oxygen supply, an oxygen gauge or flow meter, oxygen tubing, source of humidification if indicated and a system for delivery (either high or low flow). • Oxygen supply can be obtained from either a piped source or a portable cylinder. All medical gas cylinders must conform to an international standard of colour coding. Oxygen cylinders are black with a white shoulder, and carry the label ‘O2’ or OXYGEN. • A gauge is required to regulate the oxygen pressure to that required when an oxygen cylinder is used. • A flow meter is required to control the flow of oxygen, which is measured in litres per minute. • Disposable oxygen tubing is required to connect the delivery system to the oxygen source. • A humidification system may be necessary, especially in situations where the upper airway is bypassed with endotracheal or tracheostomy tubes, or for long-term therapy. Oxygen is ideally warmed before it is administered to the patient.

Systems for the delivery of oxygen Oxygen delivery systems can be divided into two general categories, namely low-flow and high-flow systems. Systems are chosen according to an individual patient’s needs, and according to the advantages, disadvantages and limitations of each system. • Low-flow systems. With these systems, patients receive oxygen via the flow system but also draw in room air to meet their minute ventilation needs, therefore the fraction of inspired oxygen (FiO2) that the patient receives is determined by the amount of oxygen being delivered, the patient’s respiratory pattern and the amount of air drawn from the atmosphere or from a reservoir. The reservoirs can be a reservoir bag, the oropharynx or nasopharynx. Delivery of oxygen with lowflow systems is achieved via nasal cannula or simple partial rebreathing or nonrebreathing facemasks. • High-flow systems. High-flow systems deliver enough gas to meet the patient’s minute ventilation needs – that is, all of the patient’s inspired volume. The FiO2 delivered is predictable as there is a fixed air-to-oxygen entrainment ratio. The patient’s ventilation pattern does not affect the concentration of oxygen delivered. 323

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Included as high-flow systems are the venturi mask, large-volume aerosol systems, manual resuscitation bags, CPAP circuits and mechanical ventilators. Oxygen delivery systems

The various oxygen delivery systems are described in the boxes that follow.

Nasal cannula This is made of lightweight plastic and consists of tubing that fits around the patient’s head with two prongs that fit into the nose. To ensure successful use, the nose should be free of secretions and the tubing and prongs must be correctly positioned. Advantages • It is comfortable and well tolerated. • It is relatively inexpensive. • It does not interfere with the patient’s ability to talk, eat, drink or expectorate. • Oxygen can be humidified during delivery. • It does not bypass the patient’s own anatomic structures for humidifying and Figure 17.8 Nasal cannula in situ warming of incoming air. • It can be used if the patient is mouth breathing, as oxygen enters the naso and oropharynx and can be breathed in from these reservoirs. Disadvantages • It easily becomes dislodged. • High gas flows may irritate the nasal mucosa, causing crusting and possibly epistaxis. • Long-term use may lead to pressure sores on the nose and/or ears. • Oxygen does not enter the anatomic reservoirs if the nasal passages are obstructed. • If the patient’s respiratory rate should increase, increased amounts of room air will be drawn in, decreasing the FiO2. This type of system is unsuitable for patients with tachypnoea. • The nasal cannula can only deliver 24–44% oxygen. 100% oxygen set at 1 i/min delivers 24% O2 (FiO2 of 0.24); 2^/min 28% (0.28); 3^/min 32% (0.32); 4^/ min 36% (0.36); 5^/min 40% (0.40); and 6^/min 44% (0.44). Higher flow rates do not deliver appreciably higher FiO2 levels.

Simple facemask A simple facemask is made of lightweight plastic with vent holes on the side that allow for the entrainment of room air. A simple facemask increases the anatomic reservoir and can deliver up to 60% oxygen.  ➙

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The metal nosepiece must fit tightly over the bridge of the nose to obtain a good seal. Advantages • It can be used with humidification. • It is lightweight and easy to use.

Air and oxygen mixture flows in the direction of the nose

Disadvantages • If the flow rate is too low, exhaled gases high in carbon dioxide collect Mixed gas inside the mask and can be rebreathed. • It may make the patient feel claustrophobic. • The patient cannot eat, drink or expectorate without first removing Air the mask. In many units, a nasal cannula is used when the mask Figure 17.9  Simple facemask needs to be removed. • It can be uncomfortable over the ears and nose. • It may be drying and irritating to the conjunctivae. • At low flow rates, some rebreathing of carbon dioxide may occur. • It can only deliver a maximum of 60% oxygen.

Air O2

Partial rebreathing mask This is similar to the simple facemask, but with the addition of an oxygen reservoir that allows the delivery of higher concentrations of oxygen. The mask must fit tightly over mouth, chin and nose, and the oxygen flow rate should be adjusted so that the reservoir bag only partially deflates during inspiration. Some exhaled air enters the reservoir and is rebreathed, but this air comes from the anatomic reservoirs that do not participate in gas exchange and is therefore still rich in oxygen.

Mask strap O2 line Reservoir bag partially deflates A. Inhalation

Figure 17.10  Partial rebreathing mask 

Reservoir bag expands fully

B. Exhalation ➙

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Advantages • It can deliver 70–80% oxygen. Disadvantages • If an insufficient flow rate is used, the patient will rebreathe carbon dioxide instead of air from the anatomic reservoirs that are still rich in oxygen. • It may make the patient feel claustrophobic. • The mask is cumbersome because of the reservoir bag. • Access to the mouth for eating, drinking and expectorating is limited, and a nasal cannula should be used during these times. • If high flow rates are used, drying and irritation of the conjunctivae may occur. • Patients requiring more than 60% oxygen are frequently dyspnoeic, and a rebreathing mask may make them feel more distressed. • A flow rate of 15^/min may be insufficient for severely dyspnoeic patients.

Non-rebreathing mask This is similar to the partial breathing mask in appearance. The non-breathing mask has one-way valves on the reservoir bag and the exhalation port to prevent the re-entry of exhaled gases into the reservoir bag, and also to prevent the entrainment of room air into the system.

Exhalation valve closes

Exhalation valve opens Valve closes

Mask strap Valve opens Reservoir bag partially deflates

O2 line

A. Inhalation

Reservoir bag expands fully B. Exhalation

Figure 17.11 Non-breathing mask Advantages • There is no rebreathing of exhaled air.

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• Oxygen concentrations of more than 80% can be delivered. Theoretically, this device should deliver 100% oxygen, but because it is difficult to achieve a very tight fit, some room air will be entrained, and delivery is therefore around 80–90%. However, patients who require more than 80% oxygen and are severely hypoxic may need ventilation rather than a facemask. Disadvantages • The disadvantages of a non-rebreathing mask are similar to those of a partial rebreathing facemask. • If the oxygen supply is disconnected or if a valve sticks, it is difficult for the patient to entrain room air and this may lead to respiratory distress.

Venturi mask This type of mask is similar to the simple facemask in appearance, but has a jet adaptor and corrugated mixing tubing situated between the facemask and the oxygen tubing. The jet adaptor has a side vent for the entrainment of room air. The concentration of oxygen delivered depends on the flow rate of gas through the jet adaptor and the masks are colour coded according to the concentration of oxygen that they deliver. The mask has side vents to allow exhaled air to escape. A venturi mask delivers between 24% and 60% oxygen.

Exhaled gas

Exhalation port Mask strap

Air entrainment port Narrowed orifice

Flex tube (15.24 cm long)

Entrained room air 100% O2

Inhaled mixture of 100% O2 and room air

Removable adaptor (jet diluter)

Figure 17.12  Venturi mask Advantages • Allows a constant ratio of room air to oxygen and therefore delivers a known FiO2. • Can be used with humidification and aerosol therapy. ➙ • As this is a high-flow system, it helps to eliminate the rebreathing of CO2.

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Disadvantages • The disadvantages of this type of mask are similar to those of other masks. • The air entrainment holes must always be open, otherwise the correct FiO2 will not be delivered.

T-piece The T-piece, T-tube, or Briggs 1980 adaptor is made of hard plastic and is intended for attachment to an endotracheal or tracheostomy tube in the patient who is breathing spontaneously. This system is used to deliver 1984 humidified oxygen to the patient with an artificial airway who is Figure 17.13  T-piece breathing spontaneously. Corrugated tubing from a blender, to which a humidifying and warming device has been attached, is connected on one side of the system, while a short reservoir of corrugated tubing is connected on the other side. To ensure that the patient’s minute volume requirements are being met, a constant mist should be seen escaping from the reservoir end. This can be achieved by adjusting the flow rate. Oxygen concentrations of 28–100% can be delivered via this type of system. Advantages • It is lightweight and allows mobility for the patient. • The delivery of oxygen is fairly predictable if the flow is adequate. • The drying of secretions and the mucous membranes is prevented by the use of humidification and warming of incoming gas mixture. Disadvantages • The tubing can become saturated with condensed water, which can then drain into the airway. • If the high flow rate is not maintained, room air will be entrained and the FiO2 will no longer be constant.

Tracheal mask This is a lightweight mask designed to fit over the opening of a tracheostomy tube. It has an exhalation port and is connected to a blender and humidification/warming system using corrugated tubing. The collar should fit snugly against the patient’s neck by adjusting the neck strap. If the flow rate is adequate to meet the patient’s minute volume needs, a constant mist should be seen leaving the exhalation port. ➙

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Advantages • It enables accurate delivery of oxygen if the collar is properly secured around the patient’s neck. • The high humidity and the warming system prevent the drying of secretions. • A swivel adaptor allows for patient mobility. Disadvantages • Condensation can build up in the Figure 17.14 Tracheal mask corrugated tubing and drain into the tracheostomy. • Secretions can build up in the collar and act as a source of infection. • Entrainment of room air can occur if the flow rate is not high enough, and the FiO2 will no longer be constant or reliable. • The mask may become displaced.

Continuous positive airways pressure (CPAP) CPAP entails the application of positive pressure to the airways throughout the breathing cycle in a patient who is breathing spontaneously. The patient breathes out against a constant positive pressure, which encourages the opening up of collapsed airways and alveoli. Lung compliance and the work of breathing may be improved. Indications for the use of CPAP are as follows: • It can be used for hypoxia in a spontaneously breathing patient with a normal respiratory drive. • It can be used for the interior stabilisation of the chest wall, as in a patient with a flail chest. • Continuous positive pressure can be used to limit the amount of fluid leaking into the alveoli in a patient with pulmonary oedema. • CPAP is commonly used during weaning from mechanical ventilation as the work of breathing is reduced. Advantages • The need for mechanical ventilation with its attendant complications may be averted. • CPAP can be applied using a mask or via an artificial airway. • The incidence of nosocomial infection is decreased if the patient can avoid having an artificial airway inserted. • The patient breathes spontaneously while receiving the benefits of positive end expiratory pressure (PEEP) – that is, opening of alveoli, improved oxygenation and improved lung compliance. • The strength and function of the respiratory muscles are maintained. ➙ • CPAP can be applied using a ventilator.

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Disadvantages • The patient often poorly tolerates a CPAP mask as it can feel very claustrophobic. • Skin breakdown and pressure sores may occur under the tightly fitting mask. • In many of the CPAP delivery systems, other than a mechanical ventilator, there is no alarm system. • CPAP increases intrathoracic pressure throughout the respiratory cycle, which may cause barotrauma. • The increased intrathoracic pressure may also cause an increase in intracranial pressure, which may limit the use of CPAP in patients with neuro-trauma. • The decreased venous return may decrease the cardiac output, and in turn lower the blood pressure. • If the patient is not intubated, CPAP can lead to gastric distension and vomiting, with the danger of aspiration. Inserting an orogastric drainage tube can alleviate this problem. Prescribed FiO2 (air/O2 mixture)

T-piece

Figure 17.15  CPAP circuit

Humidification systems Under normal conditions, incoming air is warmed and moistened by the mucous membranes of the nose, pharynx and larynx. However, during the administration of supplemental oxygen therapy, humidification of the inspired gas is required because, in contrast to normal room air, banked oxygen is very dry. When the upper airway has been bypassed by an artificial airway, such as an endotracheal or tracheostomy tube, humidification is essential. Indications for humidification include disease conditions leading to thick, tenacious secretions, high flow rates of oxygen, and intubation with an artificial airway.

Cold humidification systems In cold humidification systems, oxygen passes through cold water from a narrow tube placed under the water level of the humidifier. Passing the oxygen through a narrow tube forces the gas to break up into small bubbles, becoming visible as steam or vapour in the humidification chamber. Only about 50% of the incoming gas can be humidified by a cold water system.  ➙

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The advantages of cold humidification systems include the fact that they are simple in design and easy to use, and many come as disposable units. The main disadvantage of such a system is precisely the fact that only 50% of the incoming oxygen is humidified, which may still lead to drying of secretions if the system is used over a long period of time. Warm humidification systems Warm humidifiers force the oxygen through a heating grid and then through a mesh, which breaks the incoming oxygen up into small bubbles. The bubbles then move through a chamber of heated water where 100% of the incoming oxygen is humidified. The smaller the bubble size, the more efficient is the humidification obtained. The advantages of warm humidification systems include the fact that they supply heat as well as moisture to the incoming oxygen, and they allow 100% humidification of the incoming oxygen. Disadvantages of these systems include the cost of maintenance, as these devices are all reusable. Reuse also increases the risk of infection to the patient, because bacteria may grow in the device. Overheating may cause burning of the airways. If the incoming oxygen is very humid, the respiratory tract absorbs water, which leads to fluid overload, especially in infants.

The artificial airway An artificial airway is a device that is designed to keep the patient’s airway open when the patient is unable to do so. Artificial airways include pharyngeal, endotracheal and tracheostomy tubes. These tubes are specifically designed to optimise airway control in situations when the patient is unable to maintain this function voluntarily or effectively. Artificial airways may be designed for short-term use or for use over longer periods of time, depending on the needs of the patient. The artificial airway is used to: • prevent airway obstruction that may occur due to loss of oropharyngeal muscle tone and weak oropharyngeal reflexes • facilitate the removal of secretions from the airway • prevent aspiration by using a cuffed artificial airway tube in patients whose cough and gag reflexes are depressed or absent • facilitate mechanical ventilation by providing control over the airway and by sealing the airway with the use of a cuffed tube.

Oropharyngeal airway The oropharyngeal airway is made of hard plastic and is designed to prevent the tongue from falling back and obstructing the airway. The airway has a hard oral flange that fits against the patient’s lips, and a curved body that fits into the oral cavity. Before inserting, the nurse must select the correct size by placing the airway at the corner of the patient’s mouth and checking to see that the tube extends to the bottom of the ear on the same side. Indications include: • altered level of consciousness resulting in loss of oropharyngeal muscle tone • prevention of biting where an oral endotracheal tube is in situ. ➙

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Advantages • It is easy to use and to insert. • It provides a serviceable airway during an emergency. • It enables secretions to be suctioned from the oropharynx and larynx. Disadvantages Figure 17.16 Oropharyngeal airway • The tube can be very irritating to the conscious patient, causing gagging and vomiting. • This type of tube is not suitable for patients who have undergone oral surgery or who have suffered trauma to the mouth and oral cavity.

Endotracheal tube Endotracheal tubes can be inserted via the nose or mouth. The tube is designed to extend from the mouth to just above the carina in the trachea. The tubes have a standard curvature and are equipped with an external connector to attach the patient to a ventilatory device. The internal end of the tube is bevelled to prevent trauma. Adult tubes have a cuff just above the bevelled end to allow the lungs to be sealed off during mechanical ventilation. Indications for the insertion of an endotracheal tube include: • to protect the airway and prevent aspiration in patients with decreased level of consciousness, or who have depressed cough and gag reflexes • obstruction of the upper airway • to allow the patient to be attached to a mechanical ventilator. Once inserted, tube placement must be checked by means of a chest radiograph and by listening for breath sounds. Advantages • This tube gives control over the patient’s airway. • It allows for the removal of secretions from the trachea and large bronchi. • It allows for mechanical ventilation. Disadvantages • The tube may be very uncomfortable for the conscious patient. • It may cause damage to the hard and soft palate by pressing against these structures. • The cuff may cause erosion of the mucosa of the trachea, causing perforation into the oesophagus or into a major blood vessel. • The pressure of the cuff may also cause damage to the C-shaped cartilaginous rings that keep the trachea open. This causes tracheomalacia, a condition in which the trachea collapses on exhalation, obstructing the airway. • Insertion of the tube is a difficult procedure and is best performed by someone who is experienced in the procedure. ➙

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One-way valve Pilot balloon

Murphy eye

Cap to oneway valve

Inflated cuff Radio opaque line

Inflating tube

15 mm adapter

Depth markings

Figure 17.17  Cuffed endotracheal tube

Tracheostomy tubes Tracheostomy tubes are made of plastic or metal in a wide variety of sizes in 0.5 mm increments for both adult and paediatric use. The tube is inserted directly into the trachea via a surgical incision in the anterior part of the neck, between the third and fourth C-shaped cartilages of the vertebral column. The procedure is best carried out electively in an operating room, but may be done at the bedside in an emergency. Indications for the insertion of a temporary tracheostomy tube are the same as those for the insertion of an endotracheal tube. Permanent tracheostomy tubes are inserted post laryngectomy. In situations requiring mechanical ventilation, an endotracheal tube is used initially, and a tracheostomy is inserted should it become apparent that the patient would require long-term mechanical ventilation.

Cuffed tracheostomy

Non-cuffed metal tracheostomy tube with inner tube (changed 4–6 hourly)

Figure 17.18  Commonly used tracheostomy tubes Advantages • It gives the same degree of control over the airway as an endotracheal tube. • The tube is much more comfortable for the patient. • It allows good access to the mouth for oral hygiene. • Conscious patients may be able to take fluids and soft food by mouth if the swallowing mechanism is intact.

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Disadvantages • The complications due to the pressure of the cuff are the same as for an endotracheal tube. • The insertion site may bleed or become infected. • The tube may become displaced into the pre-tracheal fascia.

Manual resuscitation bags The manual resuscitation bag is made of rubber or silicone, and forms part of the basic life-support equipment in all clinical settings. Resuscitation bags are available for adults and children (for babies the Allen’s bag is used, which is an open-ended bag to enable breath size to be adjusted). The bag consists of a self-inflating bag, a non-rebreathing valve, an oxygen inlet valve and a standard connector to allow the bag to be attached to a facemask, endotracheal tube or tracheostomy tube. Non-rebreathing patient valve

Intake valve

1 600 ml compressible, self-refilling ventilation bag

Cuffed adult mask

2 600 ml O2 reservoir bag

Nipple for O2 tubing

Figure 17.19  The manual resuscitation bag The manual resuscitation bag is used to: • provide positive pressure ventilation and oxygen to patients with inadequate or absent respiration • pre-oxygenate the patient and provide ventilation prior to connecting the patient to a mechanical ventilator • pre-oxygenate the patient prior to and during suctioning • maintain ventilation if there is a power failure or if the mechanical ventilator fails • provide oxygenation to patients during transport between departments. The bag can be used with a mask or with an endotracheal or tracheostomy tube. If a facemask is used, the nurse must ensure that it fits tightly to prevent the escape of air/oxygen from the system. The greatest advantage of the bag is that it is simple, effective and easy to use in an emergency while awaiting more definitive treatment. Every worker and healthcare professional in a clinical situation should be able to use a manual resuscitation bag, and its use should be taught to all staff along with basic CPR. ➙

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The disadvantages of the manual resuscitation bag include: • increased respiratory distress if the operator does not synchronise with the patient’s breathing in situations where the patient is breathing spontaneously • gastric distension and aspiration of gastric contents if the patient does not have an endotracheal or tracheostomy tube in situ • difficulty for an unskilled person on his or her own in holding the mask in place while simultaneously bagging the patient.

Nursing implications Nursing diagnoses related to unmet oxygenation needs

• Ineffective airway clearance related to excessive pulmonary secretions, tracheabronchial infection and obstruction as evidenced by ineffective cough, cyanosis and rusty sputum • Ineffective breathing pattern related to pain and anxiety manifested by rapid breathing rate • Impaired gas exchange related to lung infection as evidenced by tachycardia, dyspnoea and hypoxia • Activity intolerance related to imbalance between oxygen supply and demand evidenced by complaints of fatigue • Anxiety related to a feeling of suffocation associated with ineffective airway clearance evidenced by a rapid breathing pattern • Sleep pattern disturbance related to ineffective breathing as evidenced by orthopnoea and persistent cough.

Conclusion Oxygen is one of the basic human survival needs, and nurses should assess patients comprehensively in order to detect all situations contributing to inadequate oxygenation of tissues early and to promptly manage hypoxia and hypoxaemia in order to prevent cerebral damage.

Suggested activities for learners Activity 17.1 Mrs Thakadu presents in the clinic with a history of pain on inspiration. Movement aggravates the pain. She has a productive cough and her lips are cyanosed. • Working in groups, explore the data that are to be collected in relation to this patient’s pain in the chest, difficulty in breathing, cough and cyanosis. • Draw up a care plan that will allow for adequate ventilation and oxygenation. NB! Support your presentation with related physiological aspects and state the prognosis thereof.

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Activity 17.2 The class should be divided into groups of four or five. Each person in the group should prepare and give a talk to the rest of the group on one of the following topics: • Oxygen therapy and humidification • Collection of sputum specimen • Advice to the family of a patient who is suffering from tuberculosis and who is being cared for at home • Measures to promote effective cough.

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Learning objectives On completion of this chapter, the student should be able to do the following: • Accurately monitor and interpret cardiovascular parameters. • Plan and implement nursing interventions designed to relieve strain on the heart and/or improve cardiac output. • Assess the cardiovascular system. • Identify abnormal functioning of the system.

Key concepts and terminology Apical pulse: Pulse rate measured at the apex of the heart. Arteries: Large blood vessels that carry blood away from the heart. Arterioles: Small arteries that are able to constrict and dilate due to the fact that their walls consist of smooth muscle. Blood pressure: Blood pressure is the pressure exerted by the blood against the walls of the large arteries. Bradycardia: Abnormally slow pulse rate. Capillaries: Smallest blood vessels, which have walls that are one cell layer thick. Cardiomegaly: Enlargement of the heart. Central venous pressure: Pressure exerted by the blood in the great veins and left atrium. Circulation: Movement of blood through the blood vessels throughout the body. Diastolic blood pressure: Pressure during relaxation of the heart. Haemodynamic monitoring: Monitoring of all the factors that influence the circulation of blood. Hypertension: Abnormally high blood pressure. Hypotension: Abnormally low blood pressure. Hypoxia: Reduced oxygen uptake in the brain. Pulse: The contractions of the heart as measured at the periphery.

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Pulse oximetry: The continuous monitoring of peripheral tissue oxygen saturation (SaO2). Shock: Circulatory failure characterised by a very low cardiac output and severe hypotension. Systolic blood pressure: Pressure during contraction of the heart. Tachycardia: Abnormally fast pulse rate. Veins: Tubes in the circulatory system that carry blood from the tissues back to the heart.

Prerequisite knowledge The nurse should have knowledge of the following: • Normal anatomy and physiology of the cardiovascular system • Patient assessment • Identification of bio-psychosocial needs.

Medico-legal considerations The scope of practice of registered nurses authorises nurses to maintain the following functions related to the heart and circulation: • Supervision over and maintenance of a supply of oxygen to a patient • Supervision over and maintenance of fluid, electrolyte and acid-base balance of a patient. In order to maintain these functions, nurses must use a variety of skills, depending on their knowledge and expertise. Nurses use the skills that they are competent in, which could include the following: • Maintenance of optimum cardiac output and rhythm. First, this refers to the proper observation and recording of vital signs to provide an overview of the patient’s condition and the disease process. This often necessitates rapid action on the part of a nurse, who could be required to institute treatment while awaiting the arrival of a doctor. In some institutions, standard protocols are used for this type of situation, but the legality of such protocols is not fully established. In such circumstances, the nurse takes action to meet the need of the patient, and is held fully accountable for this. These incidents should be fully documented and validated by the patient’s doctor at the earliest opportunity • Assessment and management of fluid status, which may include setting up and initiating intravenous therapy, as well as the management of fluid restriction and monitoring of output • The administration of oxygen with full knowledge of the correct use and application of the different types of oxygen masks or nasal cannula to ensure that the correct percentage or flow is administered • The management and care of patients with cardiac and/or circulatory assistive devices in situ, such as a pacemaker ➙

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• The monitoring and management of patients with invasive monitoring devices in situ, such as a central venous pressure line or an arterial line • The monitoring and management of patients with invasive monitoring devices such as an arterial line or pulmonary artery catheter.

Key ethical considerations The effectiveness of modern resuscitation techniques begs the question of whether these techniques should always be used, especially in the case of patients suffering from chronic and intractable cardiac and circulatory conditions that are resistant to treatment. Instructions not to resuscitate, or ‘NO RESUS’ orders, are often given in the case of this type of patient. Such ‘NO RESUS’ orders should be given only after a proper process of ethical decision making has been followed. A nurse should act as a patient advocate and ensure that the rights of the patient and family are protected, as a ‘NO RESUS’ order may be equivalent to euthanasia. ‘NO RESUS’ orders, if valid and properly issued, should be respected: it only creates further problems and pain if individuals act on their own initiative and resuscitate the patient after everything possible has been done for the patient and such an order has been given. On the other hand, a ‘NO RESUS’ order does not mean that the patient may be neglected in any way. The patient must be kept comfortable and all necessary basic nursing care and psychological support should be given.

Essential health literacy Cardiovascular diseases are a leading cause of death and chronic ill health in South Africa. The community must be made aware of factors that contribute to cardiovascular diseases and of ways of preventing them, or at least identifying them at an early stage when they can be controlled. The following are important factors: • Cigarette smoking is an important contributing factor in cardiovascular disease. Smoking has been implicated as a causative factor in ischaemic heart disease as well as hypertension. Nicotine contained in cigarettes alters the behaviour of the platelets, making them sticky. They then adhere to vessel walls and may cause a blood clot to form. Nicotine is also a sympathetic nervous system stimulant, causing vasoconstriction and an increased heart rate, which contributes to the development of hypertension. All health workers have a duty to model good health behaviours in the community, and should not be seen to be smoking – or at least not while on duty in a healthcare facility. • The beneficial effects of exercise on the cardiovascular system are well known, and everyone should be encouraged to do some form of exercise. Exercise improves cardiovascular efficiency and may help to lower blood cholesterol levels, thereby helping to prevent ischaemic heart disease. Exercise is relaxing and promotes vasodilatation, and regular exercise can help to prevent hypertension or reverse it if the disease is still in the early stages. Exercise that benefits the cardiovascular system is called cardiovascular exercise, and is the type of exercise that increases the pulse and respiratory rate as well as causing sweating. ➙

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• Community screening for hypertension is important as the disease can be controlled and sometimes reversed if it is identified at an early stage and treated promptly. Random blood pressure testing should be available at every community clinic and at a number of other locations in the community, such as chemists or in shopping malls. If an individual’s blood pressure is found to be raised on such random testing, the individual should be advised to consult his or her doctor or community clinic for more definitive investigation. • Other conditions that contribute to cardiovascular disease, such as diabetes mellitus and raised blood cholesterol, should also be screened for in the community so that the conditions can be identified and treated at an early stage. It is important to make the community aware of the significance and prevalence of these diseases, as well as the benefits of early treatment in order to persuade the community to participate in a screening programme. Stress reduction and relaxation are also significant in managing hypertension. Together with regular exercise, stress management plays an important role in reducing cardiovascular disease in the community.

Introduction The circulation system is the means by which oxygen and nutrients are carried to the tissues and organs of the body. It is important for nurses to understand the ways in which the body maintains circulation, including the factors that may influence heart rate and blood pressure. The nurse needs to develop proficiency in the specific skills and techniques used in the assessment of the cardiovascular system. Nurses also need to understand the care and management of common clinical problems related to cardiovascular function.

Clinical alert! • For accuracy of assessment, the pulse should be taken over a full minute. • The apical pulse should be assessed at the same time as the peripheral pulse at the initial assessment to ascertain whether each apical beat is transmitted to the periphery. • The patient should be resting when taking the pulse and/or blood pressure. Both of these parameters are increased by exertion and an accurate baseline assessment can be made only with the patient at rest. • The correct cuff size should always be used when taking the blood pressure. Incorrect cuff size will lead to false readings of the blood pressure.

Function of the circulatory system The maintenance of circulation is a vital bodily function. It is by means of the circulation of blood that oxygen and nutrients are transported to the tissues that need them, and metabolic wastes and toxic substances are removed. Circulation is maintained by the cardiovascular system, which consists of the heart and the blood vessels. • The cardiovascular system delivers oxygen, nutrients, hormones, antibodies and other substances to the organs and tissues in response to their needs and demands. 340

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• The continuous pumping action of the heart causes the blood to circulate, taking with it needed substances for the organs and tissues. • As the blood moves through the tissues, carbon dioxide and other waste products are taken up to be transported to the lungs, liver and kidneys for excretion. • The role of the blood vessels is to carry the blood itself and to maintain sufficient pressure in the system to ensure the continuous onward movement of the blood.

The heart The human heart beats approximately 70–80 times per minute throughout an adult person’s lifetime. Its rate may increase or decrease during certain conditions but it can never stop to have a rest when tired. The heart acts as a pump, which, when it contracts, forces blood into the lungs for oxygenation and also into the systemic circulation to carry this oxygenated blood and nutrients to all the body tissues. The heartbeat is initiated from within the heart by a specialised conduction system situated within the walls of the heart, known as the conducting system of the heart. Factors that increase the heart rate

These factors include the following: • Sympathetic nervous stimulation • Exercise • Fever • Emotion • Hormones, for example thyroxin • Electrolyte imbalance, for example hypercalcaemia, hypocalcaemia, and hyper-/ hypokalaemia • Hypoxia. Factors that decrease the heart rate

These factors include the following: • Hypertension • Hypothermia • Drugs, such as digoxin or beta-adrenergic blocking agents as well as antidysrhythmic agents • Stimulation of the vagus nerve – actions such as straining at stool, suctioning or the passing of rectal probes all cause vagal stimulation and may thus decrease the heart rate • Profound hypoxia that has affected organ function • Raised intracranial pressure.

The arteries The elastic properties of the aorta and large arteries help to maintain the smooth flow of blood through the circulation. During systole, the walls of the aorta distend. During diastole, they recoil and help to maintain the pressure and therefore the flow of blood between contractions. This elastic recoil also has the tendency to keep the blood moving onwards. A loss of elasticity (old age) leads to a higher pulse pressure.

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The arterioles These are the small terminal parts of the arterial tree. The degree of constriction or dilatation of the arterioles helps to maintain normal peripheral vascular resistance, which is a factor in maintaining normal blood pressure and circulation through organs and tissues. Capillaries Capillaries are the smallest of the blood vessels. The exchange of gases, nutrients and metabolites between the blood and the cells takes place through their walls, which are one cell layer thick. Flow through the capillaries is slow to allow adequate time for exchange processes to take place. Veins Veins carry blood from the tissues back to the heart. They are highly distensible and can increase their capacity without causing an increase in venous pressure. The veins constitute the main reservoir of blood in the body. Blood pressure Blood pressure is the pressure exerted by the blood against the walls of the large arteries. The reason for the blood being under pressure is to ensure that: • the blood circulates at the correct rate – for constant supply of oxygen and nourishment to the tissues • capillary and tissue perfusion takes place – hydrostatic pressure of blood ensures that nourishing tissue fluid is forced through the walls of the active capillaries • waste products are forced through the glomeruli of the kidneys for excretion in the urine. The pressure during contraction of the heart is systolic, and the pressure during relaxation is called diastolic pressure. The average normal blood pressure for an adult is 110–120 mmHg (systolic), and 75–80 mmHg (diastolic). Factors that maintain normal blood pressure

• The cardiac output, or the amount of blood pumped by the heart every minute – this would depend on the strength of the pumping action of the heart as well as the total blood volume. • Peripheral resistance of the arterioles to the flow of the blood, which determines diastolic pressure. The arterioles control capillary perfusion. Constriction and dilatation of the arterioles allows a lesser or greater amount of blood to flow into the capillaries. • The elasticity of the large blood vessels, especially the aorta – the stretching of the elastic walls of the aorta during ventricular systole prevents the systolic pressure from becoming too high. • The viscosity (thickness) of the blood causes resistance to its flow through the smaller blood vessels. Factors that affect the blood pressure

• Age. The blood pressure normally increases with age. 342

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• Physical activity. Physical activity increases the blood pressure. It is the systolic blood pressure that is increased because the cardiac output is increased during physical exercise. • Emotion. Strong emotion tends to raise the blood pressure, although it causes some individuals to become hypotensive. • Rest. The blood pressure decreases with rest and is at its lowest during deep sleep.

Nursing assessment of circulatory function A variety of factors provide information regarding the adequacy of the circulation, and nurses must assess each of these factors.

Taking the pulse Palpation of the pulse at the periphery allows the nurse to assess the rate and the regularity of the heart rate. The pulse is palpated at points where an artery passes over a bone, or where the artery is close to the surface of the body and can easily be felt. The pulse may also be taken at the apex of the heart, using a stethoscope. The stethoscope is placed over the apex of the heart (5th intercostal space – mid-clavicular line). The heartbeats are now counted for a full minute. It is sometimes necessary, in cases of irregular heart rhythm, to ascertain whether every beat heard at the apex is getting through to the periphery. To do this, the nurse counts the apex beat while keeping the fingers over the peripheral pulse and noting whether all the beats come through. If not all of the beats heard at the apex are felt at the periphery, the patient is described as having a pulse deficit.

Clavicle

Figure 18.1  Diagram showing position of the apex beat 343

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Types of pulse

Pulse can be categorised in terms of the following: • Rate. An increased heart rate is termed tachycardia. This occurs in haemorrhage and shock. A decreased rate is called bradycardia. This occurs in increased intracranial pressure, and in diseases with lowered metabolism, for example myxoedema and in digoxin overdose. • Force. The pulse can be weak, soft or feeble in hypovolaemic shock and typhoid state. The force of the pulse could be bounding, full or tense as in hypertension. • Rhythm. The rhythm may be irregular. This is known as dysrhythmia. The normal pulse should be regular.

Taking the blood pressure This is a measurement that is easily taken. It can be done in any situation, and the blood pressure provides a simple, indirect assessment of circulatory function (see Juta’s Manual of Nursing: Practical Manual, Volume 2). Temperature (See also Chapter 19: Temperature regulation need.) Since it is the circulation that ensures that heat is evenly distributed throughout the body, the difference between the patient’s core temperature and peripheral temperature can be a useful indicator of the adequacy of the circulation. Urine output and fluid balance (See also Chapter 21: Assessing and maintaining fluid, electrolyte and acid-base balance.) The patient’s urine output can also provide an indication of the adequacy of the patient’s circulation. Assessment of documented fluid balance can provide an early warning for major derangements of cardiovascular function. An excessive positive fluid balance results in fluid overload and may precipitate cardiac failure. Electrocardiogram (ECG) Continuous electrocardiographic monitoring provides information other than just the heart rate, such as the rhythm of the heart and the configuration of the cardiac complexes. Problems that may be identified include abnormal cardiac rhythm, myocardial ischaemia and myocardial infarction. Pulse oximetry Pulse oximetry involves the continuous monitoring of peripheral tissue oxygen saturation (SaO2). This measurement gives an indication of peripheral circulation, because oxygen must reach the tissues by means of the blood. Poor peripheral perfusion and vasoconstriction due to the patient being cold may limit the effectiveness of the procedure.

Additional information on assessment and monitoring techniques Arterial lines This involves the insertion of a line into a peripheral artery to allow for continuous monitoring of the blood pressure in the following circumstances: • Low cardiac output, as in shock, hypovolaemia and hypotensive anaesthesia

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• Where the patient’s blood pressure is unstable or large fluctuations in blood pressure are expected, as in uncontrolled hypertension, poor myocardial function, and major vascular or cardiac surgery • To allow for the convenient sampling of arterial blood for blood gas samples as well as other blood samples as needed. Central venous pressure (See Chapter 21: Assessing and maintaining fluid, electrolyte and acid-base balance.) The central venous pressure gives an indication of fluid status as well as circulation.

Common circulatory or cardiovascular problems Blood pressure The blood pressure may become abnormally high or abnormally low, and these conditions are described as hypertension and hypotension respectively. Although the blood pressure rises slightly with advancing age, a consistent blood pressure of 160/100 should be regarded as abnormal. Hypertension may affect the systolic or diastolic pressure, or both. • Raised systolic pressure is chiefly caused by: –– emotional factors –– pathological factors that cause the aorta to lose its elasticity – aortic incompetence –– heart block –– thyrotoxicosis. • Raised diastolic pressure is a much more serious condition, which is caused by generalised vasoconstriction and is found in: –– essential hypertension –– renal diseases –– toxaemia of pregnancy. A persistently low blood pressure, which is not severe enough to stop tissue perfusion, is not a dangerous condition, although the sufferer may complain of feeling tired. A sudden sustained lowering of the blood pressure below 100/60 is, however, very dangerous.

Hypertension Hypertension may either be primary or secondary to some other disease such as renal disorders, endocrine disorders, toxaemia of pregnancy and atherosclerosis. In hypertension, the pulse pressure is commonly increased. The pulse pressure is the difference between the systolic and diastolic pressures. For example, BP 220/120 causes a pulse pressure of 100 mmHg – this pressure will cause a hard bounding pulse. Essential hypertension may either be benign (ie slowly progressive) or malignant (ie rapidly progressive). Benign essential hypertension is a very common disorder of unknown aetiology, associated with hereditary, temperament and emotional factors. Increased peripheral resistance due to vasoconstriction and later narrowing of the arterioles characterises hypertension. This may cause the following potentially fatal complications: 345

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Renal failure

Impaired renal function is a terminal sign in benign hypertension. The malignant form of hypertension is characterised by arteriolar necrosis with early renal failure and uraemia. Malignant hypertension is further characterised by severe diastolic hypertension and papilloedema, which is swelling of the optic disc. Cardiac failure

Hypertensive heart disease is characterised by the following progression: • Cardiomegaly, or enlargement of the heart • Left heart failure with cardiac asthma • Congestive cardiac failure. Cerebro-vascular accident

The early cerebral manifestations of hypertensive disease are the following: • Headache • Dizziness and vertigo • Hypertensive encephalopathy • Cerebral haemorrhage • Thrombosis. The eyes

The eyes are always affected during the course of hypertension. Ocular symptoms may include the following: • Subconjunctival haemorrhages • Haziness of vision • Sudden loss of vision • Diplopia and retinal changes – the changes in the retinal vessels give an accurate reflection of the progression of the disease. Treatment of hypertension

Hypertension is a chronic illness that can be managed but not cured. The following should be considered: • Obesity must be avoided. • Where renal incompetence causes sodium retention, salt intake must be restricted. • Emotional stress and tension are important factors in essential hypertension, and need to be controlled, sometimes with tranquillisers. The patient can be taught how to recognise tension and how to relax as soon as it mounts up. A rest after lunch is beneficial. • Although overwork is not a specific risk factor, an excessive workload may contribute to stress. The patient should be advised to reduce his or her workload, and may need some advice in order to be able to do this. • Anti-hypertensive drug therapy is not curative but once commenced must be continued for life. Drug therapy is aimed at vasodilatation of constricted arterioles, which brings down the blood pressure but does not cure the underlying disease. Because there is no ideal anti-hypertensive drug, various combinations of drugs 346

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are used under strict medical supervision in order to guard against dangerous side effects. Health literacy

This is a vital aspect of the management of hypertension, particularly essential hypertension, as, unless the patient complies with the prescribed regime, success is impossible. Advice on prescribed dietary restrictions, including the whys and the wherefores, is essential. • It is essential that the patient knows the effects of the drugs that he or she must take, and how to take them. The patient should realise that therapy is lifelong, and that the regime must not be adjusted or tampered with without consulting a doctor. • Regular clinic follow-up is an essential part of treatment and the importance of this must be emphasised. Many patients can be taught to take their own blood pressure at home, which will greatly assist the monitoring of treatment. Specific nursing interventions

The following are interventions for a patient hospitalised for hypertension: • Provide a restful, stress-free environment. • Promote adequate rest and sleep. • Nurse at bed rest as prescribed in severe cases. • Raise the head of the bed in severe cases as prescribed. • Give sedatives as prescribed to promote rest. • Give anti-hypertensive agents as prescribed. • Potassium replacement is required if the patient is on diuretics, such as furosemide (Lasix). • Give a salt-restricted diet as prescribed. • Observe blood pressure, lying and standing, and report any changes. • Observe urinary intake and output, and daily weight. • Provide emotional support and patient education. • Motivate the patient towards compliance with the treatment regime and foster the patient’s understanding of the condition and its treatment.

Hypotension Severe hypotension may occur suddenly, as in syncope (fainting), or more gradually, as in shock. Syncope

Syncope is a sudden drop in blood pressure due to a sudden dilatation of the peripheral arterioles resulting in cerebral anoxia and loss of consciousness. This may be: • preceded by sudden announcement of bad news or sudden pain (neurogenic cause); or • due to erect posture being maintained for too long a period so that the blood drains from the brain and pools in the legs.

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Treatment

Cerebral circulation is improved by placing the patient in the prone position with the feet elevated. Syncope-prone people who are obliged to stand for long periods can have their legs bandaged, or they may wear support stockings that will ensure an adequate venous return to the heart. • Loosening constrictive clothing around the chest increases pulmonary ventilation. • A mild vasoconstrictor, like smelling salts (ammonia) or sal volatile in water to drink can be given to people who are feeling faint. Shock

Shock is a condition of acute circulatory failure, which is characterised by hypotension, impaired capillary and tissue perfusion and hypoxia (deficiency of oxygen in the tissues). A very common cause of shock is bleeding or haemorrhage. Shock is classified according to the cause: • Cardiogenic shock: In this type of shock, the heart is unable to maintain sufficient cardiac output to maintain the circulation, as in: –– myocardial infarction –– cardiac trauma and/or surgery. • Hypovolaemic shock: This is the commonest type of shock, and results from loss of blood volume or plasma volume, as in: –– haemorrhage –– loss of plasma, as in burns –– severe dehydration. • Distributive shock: In this type of shock, peripheral blood vessels become so dilated that blood flows very slowly and pools in the peripheral blood vessels, resulting in a fall in cardiac output and blood pressure. • Neurogenic shock: This is due to loss of vasomotor control, caused by loss of nerve control over the diameter of blood vessels. • Anaphylactic shock: This occurs due to a massive release of histamine in response to allergic hypersensitivity. • Septic shock: This occurs as a result of overwhelming infection where bacterial toxins as well as chemicals released during the inflammatory response cause massive dilatation of blood vessels. Management of haemorrhage

• Lie the patient flat to improve cardiac output. • Ensure a clear airway and give oxygen by mask or ambu-bag if it is available. • Stop bleeding in the case of visible or external haemorrhage by: –– direct pressure on the wound –– pressure applied to pressure points –– the use of tourniquets. • In the case of concealed or internal haemorrhage, the patient requires emergency surgery. In this situation, an optimum cardiac output is maintained by the use of intravenous fluids and the patient is rushed to theatre as quickly as possible. 348

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• Replace lost body fluids. In this case, where whole blood has been lost, although blood is the ideal replacement, this is not always possible or desirable; plasma volume expanders may be used instead. If nothing else is available, crystalloid fluids may be used. The patient should be very closely observed until he or she is stable and out of danger.

Abnormal cardiac rhythm The normal rhythm of the heart is known as sinus rhythm because this rhythm originates in the sinu-atrial node and is conducted in the normal manner throughout the conducting system and ventricles. Dysrhythmias

Abnormal cardiac rhythms are known as dysrhythmias. A dysrhythmia means an abnormality of rate, rhythm or contractility of the heart muscle. A variety of general causes have been identified. These include the following: • Electrolyte imbalance, especially potassium, ischaemia and hypoxia • Degenerative changes due to old age • Congenital abnormalities of the heart and of the conducting system • Damage to the myocardium.

Conclusion The heart is the powerhouse of the body as it pumps blood through the lungs for oxygenation and throughout the body to provide oxygen and nutrients to the tissues and organs. This function is one of those life-supporting activities without which life is not possible. Haemorrhage, if in great amounts, is life threatening, hence conditions such as hypovolaemic shock and those affecting the pumping capability of the heart should be regarded as emergencies. In providing basic nursing care, the nurse must plan and provide for nursing interventions that sustain the circulation of blood.

Suggested activities for students Activity 18.1 Working in pairs, take each other’s pulse and blood pressure. • Record these on the form used in your institution. • Give an interpretation of each recording in relation to its physiology.

Activity 18.2 In a medical ward, look for a patient with a medical diagnosis of essential hypertension. Check the patient’s pulse and blood pressure, and comment on the findings, especially in relation to your findings in Activity 18.1.

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Activity 18.3 • The class is to be divided into groups not exceeding 10 per group. Each group is to develop a poster that will be used for health education in the local community clinic. • The poster is to depict the pathophysiology of two or three cardiovascular diseases, their causes, management, prevention and control. • The winning poster should be explicit and effective in terms of communicating the message to the lay community.

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Temperature regulation need

Learning objectives On completion of this chapter, the student should be able to do the following: • Define body temperature. • Identify the normal average and range of body temperature. • Demonstrate an understanding of the ways in which the body maintains its normal temperature, including the factors that may influence it. • Undertake the care and management of common clinical problems related to temperature regulation.

Key concepts and terminology Crisis: Where a high temperature drops rapidly to normal or below normal. Fever (medical term is pyrexia): An abnormal increase in body temperature, usually above 37.8°C and accompanied by shivering and headache and, in severe instances, delirium. Heat stroke: A condition characterised by collapse following exposure to a very high temperature of 40°C or higher. Hyperpyrexia: A very high body temperature of more than 40°C, indicative of severe infection. Hypothermia: An abnormally low body temperature (below 35°C), usually as a result of exposure to low environmental temperatures. Lysis: A slow or gradual drop in body temperature in febrile diseases associated with abatement of symptoms. Pyrexia (or fever): An increase in body temperature, raised up to 40°C, indicative of infection or exposure to very hot environmental conditions. Rigor: A severe febrile reaction, characterised by a rapid rise in body temperature, followed by a sudden drop in body temperature. Thermogenesis: Generation of heat in the body usually from physiological chemical responses such as metabolism, shivering and pilo-erection.

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Prerequisite knowledge The nurse should have knowledge of the following: • Comprehensive assessment of the patient • Anatomy and physiology of the nervous system, skin, cardiovascular system and respiratory system • Physical science associated with heat production and loss • Record keeping.

Medico-legal aspects • Failure to assess and monitor the body temperature of the patient may lead to misdiagnosing and overlooking an infection or other health problems, which may be detrimental. • Maintenance of the patient’s body temperature within the normal range is an independent function of the nurse. Failure to record the patient’s temperatue and/or report an abnormal change constitutes misconduct, which can result in disciplinary action taken against the nurse.

Key ethical considerations Failure to accurately assess vital signs, including body temperature, may lead to incorrect treatment. Inaccurate assessment may also result in failure to identify, in good time, problems and/or changes in a patient’s condition, such as the onset of infection. Dishonest recording of vital signs, including body temperature will have the same effect as above. It is a nurse’s duty to ensure the accurate assessment and honest recording of vital signs such as body temperature.

Essential health literacy • Persons at risk for hyper- or hypothermia – that is, those living and working in very hot or very cold environments, as well as those charged with the care of the very young and the very old – should be educated on measures to prevent these problems from occurring. • South Africa has a hot climate in summer, and any person who exercises in the heat should be made aware of the potential danger of heat stroke. • It is important for all joggers and cyclists to drink adequate fluids while exercising. It is also important for sportsmen and sportswomen to refrain from exercise if they are not well, as this might increase the risk of heat stroke and other complications. • Clinical thermometers are relatively inexpensive and are useful items to have in the home first-aid box or medicine cupboard. Community members should also be taught the correct use and handling of home clinical thermometers. It is advisable that parents take children’s temperatures at home per axilla and not rectally, because of the potential for injury if rectal thermometers are not used correctly. ➙

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• Clinical thermometers can be a danger in the home, especially if small children are present, as they break easily, and the mercury and glass may be swallowed, and glass may cut the skin. Thermometers should be kept in a safe place out of the reach of children. • Infants and toddlers have an immature temperature-regulating mechanism, and are sometimes inclined to develop inappropriately high temperatures for what is normally a mild illness such as flu. If a child does develop a very high temperature, simple temperature reduction methods can be used, such as removing excess clothing or bedclothes, increasing fluid intake and giving a tepid sponge down. If the pyrexia does not settle, the child should be taken to the nearest clinic, casualty or doctor’s office. • The nervous system of a very small child is also much more sensitive to a high temperature than an adult’s is. Many toddlers and infants are at risk of febrile convulsions when their temperature is very high, causing great alarm in the household. If a child does have a febrile convulsion, the first thing the parent must do is reduce the child’s temperature. This can be done by removing all clothes and giving the child a tepid sponge down. A cool environment may be maintained by putting on a fan and opening windows, taking care not to cause a draught or to chill the child. A paediatric dose of a simple antipyretic such as paracetamol 5 ml stat can be given when the child regains consciousness. The convulsions are usually of a short duration and the temperature usually drops, sometimes to below normal. Once the temperature and the convulsions have been brought under control, the child should be seen at a clinic, casualty or doctor’s office.

Introduction Despite extremes in environmental conditions and physical activity, temperature control mechanisms in human beings keep the body core temperature relatively constant. Body temperature is the degree of heat maintained by the body or it is the balance between heat produced in the tissues and heat lost to the environment. The physiological function of temperature regulation, or thermoregulation, is the process whereby the temperature is kept within the normal range. The normal range of body temperature is 36–37°C, depending on the site where temperature is measured. This is the optimum temperature range for normal body processes. It is maintained by keeping a balance between heat production and heat loss. The development, implementation and evaluation of effective care plans for the patient with an altered body temperature are thus important aspects of basic nursing care.

Temperature and the mechanisms of heat production and heat loss Heat production Heat is produced in the body through three mechanisms: 1. Metabolism of foodstuffs. During cellular metabolism, foodstuffs are broken down in order to release the energy contained within them. Most of this energy is transferred to adenosine triphosphate (ATP). ATP is a chemical that is used for 353

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the storage of energy within the cells. However, not all of this energy contained in foodstuffs is transferred to ATP – some 35% is released as heat. 2. Muscular activity and movement. During muscular contraction, energy is used, and some of it is released as body heat. Muscular movement generates additional heat from friction within the tissues. 3. Blood flow. As it flows, blood causes friction against the walls of especially the arteries, but also the peripheral blood vessels. Friction also occurs as the different layers of blood move over each other.

Heat loss The heat produced by the body must be dissipated and lost to the atmosphere in order to avoid a dangerous build-up in the body. Heat loss via the skin

Heat is brought to the skin via the circulation. The skin contains a vast network of blood vessels, many of which are interconnected to form an effective ‘radiator’ mechanism for the dissipation of body heat to the environment. The amount of blood, and therefore body heat, which enters this radiator mechanism is regulated by the sympathetic nervous system, which controls the degree of vasoconstriction in the arterioles feeding the subcutaneous capillary network. Heat is transferred from the skin to the environment in several ways: • Radiation: Heat is radiated from the body as heat waves. During radiation, heat is transferred from one object to another without direct contact between them. If the heat of the body is greater than that of the environment, heat is lost from the body to the environment. • Conduction: Heat may be lost through direct contact with cooler objects where heat is transferred from the warm body to the cooler object. Heat may also be lost by conduction from the skin to the layer of air immediately in contact with the skin or clothes. Conduction will also occur if the body is immersed in cool water. In fact, water can absorb far greater amounts of heat than air can. • Convection: Heat is lost to the layer of air immediately adjacent to the skin by convection currents where warm air from the skin rises and is replaced by cooler air that is in its turn warmed by conduction. This effect is enhanced if the body is exposed to wind because the warmed air next to the skin is moved and replaced much faster. • Evaporation: When water in the form of sweat dries and evaporates from the skin surface, heat is lost, as heat must be used in order for evaporation to take place. Insensible loss of +600 ml per day takes place even when the individual is not actively sweating. About 12–16 kilojoules per hour are lost due to this insensible loss. Regulating the rate of sweating can control the rate of heat loss by evaporation. Evaporation is an essential heat-loss mechanism when the temperature of the ambient air is very high. For as long as the temperature of the surrounding air is cooler than that of the skin, heat can be lost by radiation, conduction and convection. However, if the surrounding temperature is greater than that of the body, the body will gain heat by the above354

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mentioned mechanisms, unless sweating occurs, which allows heat to be lost by evaporation. Clothing affects heat loss by conduction and convection: air is trapped next to the body by the fabric of the clothing, reducing conduction. Obviously this varies according to the weight, number and thickness of the clothes.

Heat loss from other sources Body heat is also lost via exhaled air, as well as via urine and faeces. Exhaled air, urine and faeces are all at body temperature when eliminated, which removes heat from the body, hence a person with diarrhoea becomes hypothermic if the diarrhoea is not controlled.

Regulation of body temperature The temperature control centre is located in the hypothalamus. The pre-optic area of the hypothalamus contains large numbers of neurones that are sensitive to temperature changes. Some of these neurones are sensitive to heat, while others are sensitive to cold. These heat-sensitive neurones are stimulated by an increase or decrease in body temperature. The skin, abdominal viscera and the spinal cord also contain heat and cold receptors, which are stimulated by an increase or decrease in body temperature. Stimulation of these receptors triggers reflex actions designed to increase or decrease body temperature and to maintain it within the normal range. When the body is too hot, the following temperature-reducing mechanisms come into play: • Vasodilatation takes place throughout the skin, and sweating increases. This increases the amount of heat lost by radiation, conduction, convection and evaporation. • Heat-generating activities, such as shivering, are strongly inhibited. Indeed, the individual is inclined to feel lethargic in hot conditions. This minimises bodily activity and therefore heat production. When the body is too cold, temperature-increasing mechanisms are induced: • Blood vessels supplying the skin become constricted (vasoconstriction takes place). This reduces the amount of heat brought to the surface, and reduces heat loss through radiation, conduction, convection and evaporation. • Pilo-erection (goose bumps) occurs. The erection of the body hairs allows a layer of air to be trapped next to the skin, where this air can be warmed, forming an insulating layer of warm air next to the body. This mechanism is important in animals but is of minimal significance in humans. • Shivering triggered by the hypothalamus increases heat production. Impulses arise in the primary motor centre for shivering, which is situated in the posterior part of the hypothalamus. The muscular activity that occurs during shivering produces heat and increases body temperature. • Sympathetic stimulation of heat production occurs through an increase in the rate of cellular metabolism. Chemical thermogenesis results from the action of adrenaline and noradrenaline. This chemical thermogenesis involves the uncoupling of oxidative phosphorylation, which means that all of the energy released from food is released in the form of heat instead of being stored as ATP. 355

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• Thyrotropin-releasing hormone is secreted by the hypothalamus. This in turn causes the release of thyroid-stimulating hormones from the pituitary gland, causing the production of thyroxin by the thyroid gland to be increased. This increased production of thyroxin causes a long-term increase in cellular metabolism, which is one of the ways in which the body adapts to a colder climate. In addition to these subconscious reflex mechanisms, conscious behavioural control of body temperature also takes place. • When the body temperature is too low or too high, signals from the temperaturesensitive neurones in the hypothalamus cause an individual to perceive that he or she is too hot or too cold. • The individual then takes appropriate measures to adjust body temperature: clothing is added or discarded, physical activity may be increased or decreased, or a warmer or cooler position may be sought in order to feel comfortable and maintain body temperature within the normal range.

Normal variations in body temperature • Body temperature is lowest in the early morning, when metabolic rate and heat production are at their lowest. • The temperature is highest in the afternoon and early evening when we are active. • Temperature regulation varies with age. –– Infants have an immature thermoregulatory mechanism and their temperature is greatly influenced by the environment, which is why they need protection from extreme alterations in environmental temperature. –– Children’s temperatures are more labile than those of adults. –– Elderly people have decreased thermoregulatory controls and are also more sensitive to extremes of environmental temperature changes. Elderly individuals are particularly at risk for hypothermia for a variety of reasons, such as poor activity and poor diet, as well as poor temperature-regulating mechanisms. • Exercise or physical labour will increase body temperature due to the increase in muscular activity. • The action of hormones may have an effect on body temperature. At ovulation, a woman’s body temperature may increase by +1°C, due to the influence of progesterone. Just prior to ovulation, the oestrogen peak may cause a slight decrease in body temperature. Thyroxin, adrenaline and noradrenaline all increase body temperature. • Heat production is increased by stress, due to the action of adrenaline and noradrenaline. • Emotions stimulate the sympathetic nervous system with the release of epinephrine and norepinephrine, which increases the metabolic activities of the body tissues, which in turn increases heat production, and therefore temperature.

Measurement of body temperature Body temperature is measured using a variety of thermometers such as an oral mercury thermometer, a tympanic/aural mercury thermometer or an electronic digital 356

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thermometer. The sites for measuring body temperature include the mouth for oral temperature, the axilla, the groin, the skin on the forehead, the ear and the rectum. Table 19.1 indicates normal range readings in the various sites. Table 19.1  Normal range readings in the various sites Site

Normal range reading

Oral temperature

36.1°C – 37.2°C

Axilla or groin

35.5°C – 36.4°C

Tympanic/aural

36.4°C – 38.1°C

Rectal

36.1°C – 38.1°C

Contraindications for using the various sites to measure body temperature Contraindications for using the various sites to measure body temperature are given in Table 19.2. Table 19.2  Contraindications for using the various sites to measure body temperature Contraindications for oral

Contraindications

Contraindications

Contraindications

temperature

for axillary

for tympanic

for rectal

temperature

temperature

temperature

Babies and young children

Skin disorders

Infection and inflammation of the external and/ or middle ear

Patients with diarrhoea

Very old patients

Axillary operations

Unconscious patients

Following rectal or perineal surgery Diseases or inflammation of the rectum

Patients with seizures Confused patients Uncooperative and/or restless patients Patients who are coughing persistently and/or have difficulty in breathing Patients who are cold and shivering After drinking hot or cold fluids



➙

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Contraindications for oral

Contraindications

Contraindications

Contraindications

temperature

for axillary

for tympanic

for rectal

temperature

temperature

temperature

Very weak patients Following oral surgery

Management of common clinical problems related to temperature regulation Nursing implications • Patient safety is an important consideration when selecting a method for taking a patient’s temperature. Taking the temperature orally is not suitable for confused or unconscious patients, for children or for patients who are breathing through the mouth. • Avoid rushing the procedure for temperature taking. Always use the thermometer according to the manufacturer’s instructions. • Always check whether the patient has had anything hot or cold to eat or drink just prior to having the temperature taken, as this will affect the reading. If the patient has done so, the nurse should wait 10–15 minutes before taking the temperature. • Antipyretic drugs should be used with caution. The anti-inflammatory effect of these drugs could inhibit the normal defence mechanisms of the body.

Pyrexia • Pyrexia, or fever, is an increase in body temperature (above 37.2°C) that is part of the body’s defence mechanisms against infection. • The presence of viruses, bacteria, fungi or bacterial endotoxins in the circulation stimulates the immune system. • Stimulation of the immune mechanism triggers the production of antibodies and the activation of the inflammatory response. • As a result of these processes, substances such as complement prostaglandins, interleukins and interferon are formed, which act as internal pyrogens and which stimulate the temperature-regulating centres and increase body temperature. • This increase in body temperature causes an increased pulse and respiratory rate. The increased body temperature that occurs in pyrexia also enhances the host’s defence mechanisms. • The individual who is pyrexial feels hot, is flushed, has tachycardia and is sweating, and may experience general malaise accompanied by aches and pains as well as weakness and restlesness. • The individual has a reduced urine output. If the temperature is very high, a trace of albumen may be found in the urine on testing. Temperatures of up to 39.5°C can be considered to be a normal response to infection. • Because pyrexia enhances the host’s defence mechanisms, low-grade and moderate pyrexia should not be actively reduced with antipyretics. If, however, the temperature rises above 40°C, active reduction may be necessary. At temperatures of above 358

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40.5°C, body proteins start to become denatured or altered. Denatured body proteins are unable to perform their normal functions. Management of pyrexia

For moderate pyrexia, management is directed at maintaining the patient’s comfort. • Reduce activity through bed rest in a cool environment to decrease heat production through metabolic processes and exercise, and promote heat loss by radiation. • Remove excess clothing and bedclothes, but do not allow the patient to become chilled. • Fanning may be used, as well as tepid sponging to promote heat loss by evaporation and increase comfort. Unless contraindicated, plenty of water and other fluids should be given to replace fluid lost in sweating. • Apply ice bags on the groin, axilla and forehead to promote heat loss by conduction and convection. • Nutritional requirements are increased during pyrexia, and adequate nutrition should be given. A diet that is high in protein and kilojoules, and that contains adequate amounts of vitamins, should be provided. • Antipyretics, such as aspirin, paracetamol and indomethacin should be given only if the temperature is very high and approaching dangerous levels.

Rigors A rigor is a severe febrile reaction characterised by a rapid rise in body temperature and followed by a sudden drop in body temperature back to normal or even subnormal levels. Rigors may be caused by a variety of factors: • The onset of a febrile illness, such as flu • Incompatible blood transfusion • Contaminated intravenous fluids • Septicaemia • Malaria. A typical rigor has the following distinct stages: • Cold stage: The patient feels cold and shivers uncontrollably, which increases the temperature. The nurse should cover the patient with blankets and ensure comfort. The temperature should be recorded at regular intervals. • Hot stage: The patient feels hot and has a headache. The skin is hot and dry, and the temperature reaches its peak. The nurse should continue to record the temperature at regular intervals and the peak temperature should be noted. To maintain comfort, excess bedclothes should now be removed. Tepid sponging or fanning may also enhance comfort. Cool drinks may be given. If indicated and/or prescribed by the doctor, an appropriate antipyretic may be given if the peak temperature is in excess of 39.5°C. • Sweating stage: The temperature drops rapidly, accompanied by profuse sweating. The nurse should keep the patient dry and comfortable, and prevent chilling. The nurse must continue to record the temperature regularly. Warm drinks can be given if the patient desires them.

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Ways in which the temperature may drop

• Crisis: The temperature falls suddenly to normal over a period of a few hours, accompanied by profuse sweating and an improvement in the patient’s condition. • Lysis: The temperature falls gradually over a period of a few days, accompanied by a gradual improvement in the patient’s condition.

Malignant hyperpyrexia/hyperthermia This is a hypercatabolic syndrome, associated with the administration of general anaesthesia, and in particular with the use of suxamethonium. The condition is due to an inherited defect in the control of calcium concentrations within the muscle cell. Anaesthetic agents and depolarising muscle relaxants such as suxamethonium cause muscle fasciculation or twitching before producing neuromuscular blockade. In individuals with malignant hyperpyrexia, this low-grade activity of skeletal muscle continues, causing the body temperature to soar to dangerous levels. Although general anaesthesia is the most commonly documented cause of this condition, it is thought that malignant hyperpyrexia may also be triggered by excessive exercise, stress or fever. The clinical manifestations of malignant hyperpyrexia include the following: • An elevated body temperature, which continues to rise • Muscular rigidity • Tachycardia • Hyperkalaemia • Acidosis due to excessive lactic acid production in the skeletal muscles • Elevated levels of creatinine phosphokinase, indicating cellular and muscular damage. The condition is treated with a skeletal muscle relaxant, and this stops the excessive contractile action that pushes the temperature up to dangerous levels. Further supportive and symptomatic management includes the following: • Remove excess blankets and administer iced saline irrigations via rectal and/or nasogastric tubes. • Monitor tissue damage by regular estimations of haemoglobin, myoglobin and urinary myoglobin. • As fluid balance is extremely important, give adequate fluids orally and intravenously to maintain hydration and prevent kidney damage. • Following an episode of malignant hyperpyrexia, educate the patient about the condition, including that the wearing of a MedicAlert bracelet is mandatory. Hyperthermia/hyperpyrexia in children under five years of age may lead to febrile convulsions. The convulsions occur once in a single illness at the peak of the fever and comply with all the phases of a grand mal attack. At the end of the clonic stage of the grand mal, the temperature has decreased. Such convulsions serve as a means of muscle vibration, thus enhancing muscle activity and sweating.

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Heat stroke This condition is due to an imbalance between heat gain and heat loss due to exposure to excessive heat, usually in the sun. • The normal heat-dissipating mechanisms, such as sweating, are unable to keep up with heat gained from the environment or from bodily activity, or both. • Classic heat stroke most commonly occurs in the elderly or the very young during exposure to high temperatures. • Because autonomic nervous system function is often impaired in the elderly and immature in the infant, making heat loss difficult, this puts them at risk for heat stroke during periods of very hot weather. • Heat-loss mechanisms are also impaired in the chronically ill due to debility. These individuals are also at risk for heat stroke during very hot weather. • Heat stroke may also occur in healthy adults when heat gain exceeds heat loss. • Physical exertion carried out in hot and humid conditions, especially if the individual is not adequately hydrated, may lead to heat stroke. The clinical manifestations of heat stroke include the following: • The temperature is 40°C or higher. • Metabolic acidosis may occur due to increased lactic acid levels in exertional heat stroke. • Respiratory alkalosis is common in classical heat stroke. This is due to hyperventilation that occurs as an attempt to lose body heat by panting. • Neurological changes include confusion and impaired consciousness. • Rhabdomyolysis, due to breakdown of muscle tissue, frequently occurs and may lead to acute renal failure. • High levels of creatinine phosphokinase are found, which also indicates cellular damage. • Levels of serum amylase and aspartate are also elevated, which is another indication of cellular damage. • Cardiovascular manifestations include tachycardia and hypotension. Some victims may present with a prolonged Q-T interval, which predisposes to dysrhythmias. The Q-T interval returns to normal once the heat stroke is reversed. Treatment of heat stroke

The patient must be cooled gradually. Rapid cooling is not advisable as convulsions may occur. Effective methods of bringing about a steady decline in temperature include the following: • Fanning • Tepid sponging/spraying • Rehydration if necessary. Acid–base abnormalities should correct themselves once the primary problem of hyperthermia has been rectified. Cautious correction may be needed in cases of severe metabolic acidosis. Urine output must be carefully monitored in order to detect incipient renal failure.

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Hypothermia Hypothermia is defined as an abnormally low body temperature. For example, 35–36°C constitutes mild hypothermia, while a temperature of less than 35°C is termed severe hypothermia. • The newly born and the very old have an increased risk for accidental hypothermia because of their impaired ability to adapt to a colder environment. • The elderly in particular have both a decreased metabolic rate, as well as a diminished sympathetic vasoconstrictor response to colder conditions. • Diabetics have autonomic neuropathy, which decreases their ability to vasoconstrict in cold conditions. • Malnourished and starving people have decreased heat production, which places them at risk for hypothermia. • Burn victims may lose a considerable amount of body heat via their wounds, placing them at risk for hypothermia. Other trauma victims are also at risk through loss of blood and the exposure of injured tissues to cool air. • Patients with a decreased metabolic rate, as in hypothyroidism, produce less body heat and are therefore vulnerable to hypothermia. • Medications may also impair the body’s heat-generating mechanisms, for example muscle relaxants and phenothiazines. • Medications that impair the ability to vasoconstrict, such as beta-blockers and vasodilators, may also put the patient at risk for hypothermia. • Alcohol, coupled with exposure to cold, is often a cause of hypothermia. Alcohol depresses the central nervous system, causes peripheral vasodilatation and gives the individual a feeling of being warm. A drunk person who is exposed to cold is less likely to protect the body and is thus more likely to develop hypothermia. Clinical manifestations of hypothermia include the following: • A very low body temperature of less than 35°C is recorded. Measuring temperature in hypothermia can be problematic, and this should be done with a special lowreading rectal thermometer. • Initially exposure to cold causes vasoconstriction with increased blood pressure, heart rate and cardiac output. However, as body temperature falls, the blood pressure and heart rate also drop. • At a body temperature of 32°C or less, the victim is hypotensive and atrial, and ventricular dysrhythmias may also occur. • At a temperature of around 27°C, cardiac arrest from ventricular fibrillation occurs. • Metabolic acidosis may occur due to a build-up of lactic acid in tissues that are poorly perfused due to vasoconstriction. • Shivering may also contribute to the build-up of lactic acid. • Hypothermia also affects coagulation. • Alterations in CNS function in hypothermia begin with fatigue and apathy; progress to impaired judgement, hallucinations and bizarre behaviour; and culminate in coma. • Urine output increases in hypothermia due to a phenomenon known as ‘cold diuresis’. It is thought that this is due to a combination of factors:

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–– An interstitial space-to-intravascular compartment fluid shift –– Increased excretion of sodium by the kidney that pulls water with it –– Decreased sensitivity to ADH, which increases urinary output. • The loss of fluid via an increased urine output will increase the viscosity of the blood and may lead to thrombosis. Management of hypothermia

• • • • •

Remove the victim from the cold environment. Remove any wet clothes, as these will exacerbate heat loss. Cover the victim in warm blankets. Provide warm fluids if the victim is conscious. Use a warming blanket, although this is controversial as it can cause heat loss due to vasodilatation. Vasodilatation will increase blood flow through peripheral tissues that are cool due to the hypothermia, and may drop the victim’s temperature yet further – a phenomenon known as ‘afterdrop’.

More aggressive forms of treatment include the following: • Giving warmed intravenous fluids • Irrigating body cavities, such as the peritoneum and/or mediastinum, with warmed saline • Instituting continuous arterio-venous rewarming (see box). As a rule, passive therapies are appropriate for patients with mild to moderate hypothermia, while aggressive rewarming is reserved for patients with severe hypothermia. During treatment, blood pressure, heart rate and heart rhythm must be constantly monitored. The rectal temperature is continuously monitored using an electronic probe.

Continuous arterio-venous rewarming The femoral artery is cannulated and blood is led through a heat exchanger. The blood flows in one direction over the membrane in the heat exchanger while warm saline flows in the opposite direction on the other side of the membrane. The warmed blood is then led back to the circulation via the femoral vein.

Conclusion Measuring and monitoring of temperature is one of the basic nursing activities that nurses need to master at the beginning of their career. This activity requires cognitive skills to be able to interpret temperature readings on all types of thermometers and integrate this information into the diagnosis of patients and their management.

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Suggested activities for students Activity 19.1 A patient presents in the ward where you are working with pyrexia of unknown origin. Using all the relevant terms such as radiation, conduction, convection, evaporation, crisis, lysis and record keeping, explain the activities that you would undertake to ensure that pyrexia is managed.

Activity 19.2 In groups of not more than five per group, visit a medical ward in the institution to which you are attached and take a patient’s temperature. Record this and prepare a teaching guide that you would use to advise the patient and/or the patient’s relatives about the maintenance of normal body temperature.

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chapter

20

Nutrition

Learning objectives On completion of this chapter, the student should be able to do the following: • Recognise the importance of nutrition as being essential to health and a basic human right. • Describe the current nutrition challenges in South Africa. • Understand the general nutritional needs during each phase of the life cycle. • Demonstrate awareness of and respect for cultural and religious values; traditions; psychosocial, economic and political factors; and the beliefs and practices of people in managing nutritional needs. • Apply these concepts to provide optimal care for people, promoting health and preventing disease.

Specific outcomes To achieve the outcomes specified above, the student should be able to do the following: • Assess a patient’s nutritional status. • Implement nursing interventions designed to maintain optimum nutrition in a patient. • Implement and manage dietary restrictions and special diets. • Offer nutritional advice to patients and their families to promote health and prevent disease.

Key concepts and terminology Anabolism: The regeneration and growth of new tissue or the maintenance and repair of old tissue. Anaemia: A condition characterised by low levels of haemoglobin in red blood cells, caused by a deficiency of iron, vitamin B12 or folate, or chronic disease. Anthropometry: The use of body measurements (such as weight, height, mid-upper arm circumference, etc) to assess the nutritional status of a person. Body mass index: A formula that compares weight with height, indicating whether a person is underweight, a healthy weight or overweight, and the degree thereof. Breast milk substitute: ‘Any food or drink marketed or otherwise representing a partial or total replacement of breast milk, whether or not suitable for that purpose’ (Department of Health 2013: 67). ➙

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Catabolism: The processes whereby complex molecules from food are broken down in the body to provide energy for physiological functions. Cholesterol: A fat-like substance that is both produced by the body and found in foods of animal origin. Complementary foods: Any food (liquid, semi-solid or solid) given to children in addition to breast milk or replacement feeding to meet their nutrient needs from the age of six months onwards. Complete proteins: Foods that contain all the essential amino acids in the correct proportions. Diet history: Information on regular eating patterns, including food likes and dislikes, portion sizes, meal patterns, frequency with which foods are eaten and food availability. Enteral nutrition: Providing nutrients into the gastrointestinal tract through a tube when oral intake is insufficient to meet nutritional needs. Enzymes: Chemical substances that regulate chemical reactions in the body. Essential amino acids: The building blocks of proteins that cannot be made by the body and need to be consumed through food. Exclusive breastfeeding: Feeding only breast milk and no other foods or fluids, including water, with the exception of drops or syrup consisting of vitamins, mineral supplements or medicines (Department of Health 2013: 68). Food security: A situation where all people at all times have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life. Growth faltering: When a child does not gain adequate weight according to the growth curve over three consecutive months. Growth monitoring and promotion: Regularly measuring, recording and interpreting a child’s growth to counsel, take action and follow up results with the purpose of promoting that child’s health, development and quality of life. Hyperemesis gravidarum: Nausea and vomiting that continue throughout pregnancy, causing dehydration, electrolyte imbalance and an inadequate intake of nutrients. Incomplete proteins: Food sources that are deficient in or have limited amounts of one or more essential amino acids. Kilojoule: Unit to measure the amount of energy in foods. Low birth weight: A birth weight less than 2 500 g. Macronutrients: Nutrients needed by the body in large amounts, classified as carbohydrates, proteins and lipids (fats and oils). Malnutrition: Impaired health due to a deficiency, excess or imbalance of nutrients, including over-nutrition (excess energy and/or nutrients) or under-nutrition (deficiency of energy and/or essential nutrients). ➙

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Metabolism: All chemical processes involved in the breaking down and utilisation of nutrients by the body. Micronutrients: Natural substances found in small amounts in food that are needed by the body for tissue growth and maintenance, classified as vitamins or minerals. Mixed feeding: Giving breast milk as well as other milks (like commercial formula or home-prepared milk), foods or liquids (like water, tea, juice, etc) to a child younger than six months. Nasogastric tube: A feeding tube that is passed into the stomach via the nose, pharynx and oesophagus. Non-communicable disease: A condition that is not infectious but chronic in nature, progressing slowly and needing long-term treatment. Non-essential amino acids: Amino acids that can be synthesised by the body. Nutrients: Chemical substances contained in food and needed by the body for growth, and the maintenance and repair of tissues. Nutrition: The process by which a living organism ingests, digests, absorbs, transports, metabolises, stores and excretes/eliminates food. Obesity: An abnormal or excess accumulation of body fat, often causing impaired health, indicated by body mass index of more than 30. Over-nutrition: Nutrient intake that exceeds physiological needs. Overweight: An abnormal or excess accumulation of body fat, often causing impaired health, indicated by a body mass index of 26–30. Parenteral: Feeding and/or giving fluid directly into the bloodstream, bypassing the digestive tract. Pica: Eating substances that contain little or no nutrients such as ice, soil, charcoal or clay. Stunting: A height-for-age z-score below –2 standard deviations of the reference population, an indicator of long-term under-nutrition. Under-nutrition: Nutrient intake that does not meet physiological needs. Underweight: A weight-for-age z-score below –2 standard deviations of the reference population, an indicator of short-term or long-term under-nutrition. Wasting: A weight-for-height z-score below –2 standard deviations of the reference population, an indicator of acute, short-term under-nutrition.

Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy • Physiology.

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Key ethical considerations • Sometimes the decision of whether or not to continue aggressive nutrition support for people who are unconscious or incurably brain damaged can be controversial. • Generally, however, access to food is considered a basic physical need and a human right that should be fulfilled.

Introduction Nutrition and health are inseparable. Good nutrition is essential to good health and disease prevention while poor nutrition leads to morbidity and mortality. On the other hand, health and disease also affect a person’s nutritional status, whether directly or indirectly. More importantly, the right to have access to sufficient food and water is recognised nationally and globally as being a basic human right. South Africa is facing various nutritional challenges and is burdened with the consequences of both over- and under-nutrition. Over-nutrition is displayed in the alarming rise in the prevalence of overweight, obesity and non-communicable diseases. Under-nutrition is manifest in the persistence of stunting among our childhood population and the presence of micronutrient malnutrition, also known as hidden hunger. In spite of South Africa producing enough food at national level to meet the needs of its population, inequality in the distribution of food still causes many people to be food insecure. Any person involved in healthcare needs a basic knowledge of nutrition, the body’s nutritional needs through the life cycle and the influence of nutrition on the management of disease.

Nutrients Nutrients are the building blocks in food which people need for the growth and maintenance of all body tissues and the normal functioning of all body processes. The metabolism of nutrients in the body is regulated by hormones, and refers to a combination of processes by which energy is released from food into the body.

Macronutrients Macronutrients are those nutrients required by the body in large amounts. They can be classified as carbohydrates, proteins and lipids (fats and oils). Each macronutrient has different functions, so it is important to regularly provide the body with every macronutrient and not exclude any particular group from an eating plan.

Carbohydrates Carbohydrates are organic compounds of carbon, hydrogen and oxygen that are manufactured by plants through the process of photosynthesis. Carbohydrates provide the body with instant energy but can also be stored in muscles and in the liver to be converted quickly when the body needs energy.

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There are two basic kinds of carbohydrates: • Simple carbohydrates – sugars • Complex carbohydrates – starches and fibre. Simple carbohydrates

Sugars may be monosaccharides (single molecules) such as glucose, fructose and galactose, or disaccharides (double molecules) such as sucrose, maltose and lactose. Most sugars are produced naturally by plants, especially fruits, sugarcane and sugar beets. However, lactose (a combination of glucose and galactose) is found in milk. Complex carbohydrates

• Starches are the insoluble, non-sweet forms of carbohydrates. They are polysaccharides, which means they are made of branched chains of glucose molecules. Nearly all starches exist naturally in plants, such as grains, legumes and potatoes. Starches can also be processed in different ways, for example in cereals, bread flour, maize meal, baked products, etc. • Fibre is a polysaccharide that cannot be digested by the human body. As humans lack the enzymes necessary to digest fibre, it cannot be broken down by the body for energy but it supplies roughage or bulk to the diet. This satisfies the appetite and helps the digestive tract to function effectively and eliminate waste by stimulating peristaltic contractions in the intestinal canal. Fibre is found in the outer layer of grains, in bran and in the skin, seeds and pulp of many vegetables and fruits. Fibres are classified as either soluble or insoluble, and as these groups have different functions, the body needs both types: –– Soluble fibre dissolves in water and forms a gel. It is mainly found in fruits, vegetables, oats, brown rice, legumes and the grain psyllium. Soluble fibre binds bile acids so they cannot be reabsorbed in the colon, but rather excreted from the body. This prevents cholesterol from building up in the arteries and thereby decreases the risk for cardiovascular disease. Soluble fibre also slows glucose absorption in the small intestine, causing a more gradual increase in the blood glucose concentration. –– Insoluble fibre does not dissolve in water and is mainly found in the bran layers of cereal grains and wholegrain bread. It increases faecal bulk, decreases free radicals in the gastrointestinal tract and promotes digestion.

Clinical alert! Health benefits of fibre in carbohydrates are the following: • Prevents/relieves constipation. • Protects against colon and rectal cancers. • Prevents diverticulitis. • Reduces serum cholesterol, thereby decreasing the risk for non-communicable diseases. • Regulates blood glucose levels. 

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Most people need 25–30 grams of any type of fibre per day. Ways to increase daily fibre intake are as follows: • Eat plenty of vegetables and fruit every day. • Choose whole vegetables and fruits rather than juice. • Eat foods with whole grains instead of refined grains. • Eat dry beans, split peas, lentils and soya regularly. Functions of carbohydrates

• Carbohydrates provide energy for the body when sugars and starches are hydrolysed (broken down) into glucose. Each gram of carbohydrate (except fibre) will produce 17 kilojoules of energy. Carbohydrates are the cheapest source of energy and are available in large amounts in staple foods. • Carbohydrates have a protein-sparing effect. If glucose is available, it ensures that body protein is conserved and not broken down for energy. • Carbohydrates prevent ketosis during energy production. Ketosis develops when body fat and protein are being broken down for energy, which can lead to dehydration since more fluid is needed to excrete the ketones via the kidneys. About 100 g of carbohydrate daily is enough to prevent ketosis. • Carbohydrates provide the basic molecules needed for the synthesis of non-essential amino acids by the liver. • Carbohydrates provide the chemical precursors for the synthesis of essential substances and tissues in the body, such as bone, connective tissue, cartilage, nervous tissue and compounds involved with the deactivation of toxins in the liver. • Lactose helps with the absorption of calcium and phosphorus, as well as in the growth of intestinal bacteria that manufacture certain B-complex vitamins. • Carbohydrates provide the body with vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B3 (niacin), iron and folate. Whole grains are rich in magnesium, zinc and fibre. Sources of carbohydrates

• Starchy foods like maize meal, cereal, rice, bread, samp, pasta, potatoes and sweet potatoes • Fruit and some vegetables • Dry beans, split peas, lentils (also high in protein) • Milk and milk products (also high in protein) • Sugar (although this is not a nutritious source of carbohydrates). Carbohydrate digestion

Digestion of carbohydrates begins in the mouth when food is chewed and broken down into smaller particles. The food mass (chyme) is moved by peristalsis to the small intestine, where most carbohydrate digestion occurs. In the small intestine, pancreatic amylase breaks down complex carbohydrates into disaccharides. Disaccharide enzymes (maltase, sucrase and lactase) split maltose, sucrose and lactose into monosaccharides, which are the only form of carbohydrates the body can absorb. 370

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Carbohydrate metabolism

In the liver, fructose and galactose are converted to glucose. The liver releases the glucose into the bloodstream, where its level is maintained by the actions of hormones. The transport of glucose from the bloodstream into the cells requires the presence of the hormone insulin. If insulin is not present, glucose cannot enter the cells and remains in the bloodstream – this is what happens in people who have insulindependent diabetes mellitus. Glycaemic index

The glycaemic index (GI) of foods is a rating of carbohydrate-containing foods according to their actual effect on blood glucose levels. Foods with a high glycaemic index are rapidly broken down to release its glucose. This glucose is immediately absorbed into the circulation and triggers a sudden increase in insulin secretion from the pancreas. This insulin rapidly removes the glucose from the bloodstream, resulting in a dramatic drop in blood glucose or hypoglycaemia. Examples of foods with a high GI are white bread, brown bread, whole-wheat bread, pasta, many refined cereals, potatoes, samp, etc. Foods with a low GI are broken down more slowly, releasing glucose into the bloodstream more slowly. The dramatic increase in insulin secretion with resulting hypoglycaemia does not occur. The glycaemic effect of a low GI food will also be affected by how much of the food is eaten, so portion control remains important, as too much of any carbohydrate-rich food could have a negative effect on blood glucose control. Examples of foods with a low GI are lentils, beans, mealies/sweetcorn, sweet potatoes, seed loaf, rice, etc.

Clinical alert! Even though sugar is not an independent risk factor for any particular disease, some problems associated with too much sugar include dental caries, obesity and possibly diabetes. It is recommended that sugar and foods and drinks high in sugar are used sparingly. The following can be done to decrease a person’s daily intake of sugar: • Drink fewer fizzy drinks and cool drinks – rather have water, milk, diluted fruit juice or tea/coffee without sugar. • Enjoy fruits (including dried fruit) instead of sweets, chocolates, cakes and cookies. • Plan or prepare meals and snacks ahead of time so there is no need to buy sugary foods from shops, kiosks or vending machines. • Use sugar substitutes (sweeteners), especially in the case of obesity or diabetes.

Proteins Protein is required for growth, repair and maintenance of the body. Protein is stored in muscle, bone, blood, skin, cartilage and lymph. When the supply of carbohydrates and fats is inadequate for the body’s needs, protein can be broken down as a source of energy.

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Proteins are large complex molecules made up of individual building blocks, known as amino acids. Amino acids are organic compounds made from carbon, hydrogen and oxygen atoms. Amino acids also have a nitrogen component, which distinguishes them from other energy nutrients. There are 22 common amino acids: 10 of them are classified as essential amino acids because they cannot be made by the body and need to be consumed through food. The remaining 12 are non-essential amino acids because they can be synthesised in the liver if nitrogen and other precursors are available. Food proteins are classified as complete or incomplete: • Complete proteins are foods that contain all of the essential amino acids in the correct proportions. They must contain enough of each amino acid to meet the body’s needs. Examples are meat, milk, cheese and eggs. Soy is the only plant source that is considered a complete protein. • Incomplete proteins are food sources that are deficient in or have limited amounts of one or more of the essential amino acids. With the exception of soybeans, all plant proteins are incomplete. It is possible to combine two different incomplete proteins to make a complete one. One food may lack a certain amino acid but if that amino acid is found in another food, they can create a complete protein when eaten together. • Grains and legumes (eg samp and beans, lentil curry and rice, beans on toast, pea soup and bread) • Grains and milk products (eg macaroni and cheese, maize porridge and maas, cheese sandwich) • Legumes and seeds (eg rice salad with sunflower seeds, hummus (a spread made from chickpeas and sesame seed paste)) Functions of proteins

• Protein is required for anabolic processes in the body – the regeneration and growth of new tissue and the maintenance and repair of old tissue. Protein forms the basis of the structure of all the cells and tissues of the body, including bone, muscle and cartilage. • Protein can be converted to glucose to provide energy if carbohydrates are insufficient – this process is known as gluconeogenesis. Each gram of protein will provide 17 kilojoules of energy (the same as carbohydrates) but it requires many enzymes and additional energy to make the protein’s energy available. All the regulatory substances in the body consist of protein, for example enzymes, hormones, neurotransmitters, RNA and DNA. • Blood proteins have specific functions – haemoglobin for oxygen transport, fibrinogen for blood clotting, albumin for the regulation of fluid balance in the intravascular fluid compartment, and transferrin for the transport of iron. • Many substances are transported bound to protein to where they will be utilised, for example triglycerides, cholesterol, phospholipids, minerals, vitamins and certain drugs. • Proteins are essential for the normal functioning of the immune system as they help to create lymphocytes and antibodies. 372

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• Plasma proteins (albumin and globulin) regulate osmotic pressure in the plasma. • Amino acids help to maintain acid–base balance in the body as they bind with both acid and alkaline substances. • The retina of the eye contains a light-sensitive protein bound to vitamin A, called rhodopsin, which is essential for normal vision. • Proteins provide the body with vitamin B1 (thiamine), vitamin B3 (niacin), vitamin B12 (cobalamin), vitamin D, phosphorous, iron, zinc and iodine. Protein digestion

In the stomach, hydrochloric acid makes protein more susceptible to the action of enzymes. Pepsin breaks down proteins into smaller units. Most of the protein digestion occurs in the small intestine. The pancreas secretes the enzymes trypsin, chymotrypsin and carboxypeptidase. Glands in the intestinal wall secrete aminopeptidase and dipeptidase. Enzymes on the surface of the intestinal wall break protein down into smaller molecules and into amino acids. Protein metabolism

Proteins are broken down by the body into amino acids through the process of catabolism and then resynthesised into tissues as needed through anabolism. This continuous conversion is needed to maintain overall protein balance within the body. Sources of protein

Animal sources are fish, chicken, lean meat, eggs, milk and milk products. The best plant sources are legumes (dry beans, peas, lentils and soya), nuts and seeds. It is recommended that proteins make up to 15–20% of a person’s diet or 0.8 g of protein for every kilogram of body weight in healthy people. Although foods are often categorised as a carbohydrate, fat or protein, most are a combination of all three. Foods should rather be considered good or poor sources of a particular macronutrient such as protein. For example, a 100 g piece of chicken provides 25 g of protein; one egg (50 g) provides 7 g of protein; one slice of white bread (30 g) provides 2.5 g protein and 100 g broccoli provides 3 g of protein, therefore although all these foods contain protein, some are better sources than others. Some conditions require more protein, such as the following: • Emotional or physical stress, infection and high environmental temperatures • Times when the body must heal itself, for example after surgery, trauma or burn injuries • People with large muscle mass (as muscle tissue requires protein to maintain itself) • Catabolic conditions, for example HIV, AIDS, TB or cancer. Some people believe that a diet high in protein is beneficial to their health. Although this can help people to achieve a healthy body weight, the long-term safety of a highprotein diet has not been established. Protein sources are more expensive than other foods, and a high protein intake increases the excretion of calcium (which may increase the risk of osteoporosis) and nitrogen (which may play a role in the loss of renal function). It also increases the risk of atherosclerosis, and colon and prostate cancers.

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Lipids (fats and oils) Lipids are organic substances that are greasy and insoluble in water but soluble in organic solvents such as alcohol or ether. Lipids have the same elements as carbohydrates (carbon, hydrogen and oxygen) but contain a higher proportion of hydrogen. Fats are lipids that are solid at room temperature while oils are lipids that are liquid at room temperature. Fatty acids are the basic structural units of most lipids and can be saturated or unsaturated, according to the relative number of hydrogen atoms they contain. Saturated fatty acids are those in which all carbon atoms are filled to capacity (saturated) with hydrogen (eg butyric acid found in butter). An unsaturated fatty acid is one that could accommodate more hydrogen atoms than it currently does. It has at least two carbon atoms that are not attached to a hydrogen atom; instead there is a double bond between the two carbon atoms (eg oleic acid found in canola oil). Fatty acids with one double bond are called monounsaturated fatty acids and those with more than one double bond are polyunsaturated fatty acids. Free fatty acids are potentially dangerous as they can easily react with other molecules. To avoid biological damage, fatty acids are normally attached to a glycerol molecule. The most common are triglycerides, which consist of a glycerol molecule with up to three fatty acids attached. Cholesterol is a fatlike substance that is both produced by the body and found in foods of animal origin. Most of the body’s cholesterol is synthesised in the liver and some is absorbed from the diet through milk, egg yolk and organ meats. Cholesterol is needed to create bile acids and to synthesise steroid hormones. Phospholipids and large quantities of cholesterol are present in cell membranes and other cell structures. Functions of lipids

• Extra energy not needed by the body at present is stored in the fat cells (adipose tissues) for later use. Lipids are a concentrated source of energy, supplying 37 kilojoules per gram (as compared to 17 kilojoules per gram from carbohydrates and protein). • Lipids transport fat-soluble substances in and out of cells. • Lipids form part of bile, steroid hormones and vitamin D. • Essential fatty acids are needed for healthy skin and normal growth in children, and form part of retinal and brain tissue. • Lipids contain vitamins A, D and E, and are needed for the absorption of the fatsoluble vitamins A, D, E and K. • Fats slow down the emptying of the stomach and therefore contribute to a feeling of fullness. • Fat enhances the flavour and texture of food. • The fat layer under the skin serves as insulation and helps to maintain a constant body temperature. • Lipids in the skin act as natural lubricants, protecting and maintaining the condition of the skin and hair. • Body fat around the internal organs acts as a protective cushion, especially for the kidneys, intestines and mammary glands.

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Digestion of lipids

A minimal amount of lipid digestion occurs in the mouth and stomach. General muscle action mixes the lipids with the stomach content. When lipids enter the duodenum, the release of the hormone cholecystokinin is stimulated, which in turn stimulates the gallbladder to release bile. Bile is an emulsifier that breaks lipids into small particles and reduces the surface tension so that enzymes can penetrate the lipids and work more effectively. Lipids are mainly digested in the small intestine by bile, pancreatic lipase and enteric lipase, an intestinal enzyme. The end products of lipid digestion are glycerol, fatty acids and cholesterol. These are immediately reassembled inside the intestinal cells into triglycerides and cholesterol esters (cholesterol with a fatty acid attached to it), which are not water soluble. In order for these products to be transported and used, the small intestine and the liver must convert them into soluble compounds called lipoproteins. Lipoproteins are made up of various lipids and a protein. Metabolism of lipids

This is regulated by hormones (adrenocorticotropin, epinephrine, glucagon, glucocorticoids and thyroxine), which also promote mobilisation of lipids (catabolism). Insulin stimulates lipid synthesis (anabolism). Lipids are stored in adipose tissue within cells until needed for use as energy when each fat molecule is hydrolysed to glycerol and three molecules of fatty acids. Sources of lipids

• Saturated: Butter, cream, fat on meat, chicken skin, processed meats, cheese, full cream milk and milk products • Monounsaturated: Oils (sunflower, canola, olive), nuts, peanut butter, avocado, mayonnaise, margarine • Polyunsaturated: Seeds (pumpkin, sunflower, flax), fish (sardines, mackerel, salmon) • Trans-fats: Processed foods (biscuits, pies, pastries).

Clinical alert! Guidelines to using fat sparingly and choosing vegetable oils rather than hard fats • Choose vegetable oil and soft margarines rather than brick margarine, butter, lard or ghee. • Use a small amount of oil in cooking. • Choose low-fat sauces with pasta, rice and potatoes. • Add flavour to foods by using herbs, spices, lemon juice and garlic instead of fats, oils and rich sauces. • Cut visible fat from meat and remove the skin of chicken before cooking it. Choose meats labelled ‘lean’ or ‘extra lean’. • Enjoy healthy fats by eating fish every week. • Limit intake of organ meats, for example liver, kidneys. ➙

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• Use low-fat or fat-free milk and milk products rather than full cream. Low-fat foods must contain less than 3 g of fat per 100 g, and ‘fat-free’ foods must contain less than 0.5 g of fat per 100 g, but be aware that these products often contain sugar to enhance the taste, which adds a lot of energy to the product. • Be careful of ‘hidden fats’ in processed meats, biscuits, condiments, sauces and convenience foods. Lipids and disease

• Cardiovascular disease: Eating a diet high in saturated fats raises the low-density lipoproteins (LDL), which increases a person’s risk of developing cardiovascular disease. In coronary artery disease caused by atherosclerosis, fatty fibrous plaques progressively narrow the coronary artery lumens, reducing the volume of blood that can flow through them. • Obesity: Fats supply more energy than carbohydrates and protein, which the body can burn more easily. When a person consumes more energy than the body requires, excess fat is stored, which leads to weight gain. • Cancer: Although dietary fat has not been shown to cause cancer, it may help promote certain cancers. Research shows an association between a high total fat intake and colorectal, breast and prostate cancers.

Micronutrients Micronutrients (vitamins and minerals) are natural substances found in small amounts in food that are needed by the body for tissue growth and maintenance.

Vitamins Vitamins are organic substances needed by the body in small amounts. With few exceptions, the body cannot produce vitamins, so they must be consumed in the diet. Vitamins are necessary for many important physiological functions such as the formation of red blood cells, hormones and genetic material, and to maintain proper functioning of the nervous system. Vitamins are classified as water soluble or fat soluble: • Water-soluble vitamins are absorbed into the bloodstream directly and move freely within cells. They are not stored in the body and need to be taken in the diet daily. They can be affected by food processing, storage and preparation. They are found in the watery portions of foods and when excess amounts are consumed, they are excreted in the urine. Examples are vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B3 (niacin), vitamin B5 (pantothenate), vitamin B6 (pyridoxine), vitamin B12 (cobalamin), vitamin C (ascorbic acid), biotin and folate. • Fat-soluble vitamins are absorbed with lipids into the lymphatic system and the bloodstream. In the bloodstream they attach to lipoproteins for transport. Excess amounts of fat-soluble vitamins are stored in the liver and adipose tissue, and thus do not need to be consumed in the diet daily. They are vitamin A (retinol), vitamin D (calciferol), vitamin E (tocopherol) and vitamin K (menadione).

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Vitamin content is highest in fresh foods that are consumed as soon as possible after harvest. (See Table 20.1 for the major functions and food sources of vitamins.) Digestion of vitamins

Digestion of vitamins mainly occurs in the small intestine and requires the breaking down of food into constituent parts. Metabolism of vitamins

All vitamins are metabolised independently of one another. The process differs for each vitamin. Vitamins in health promotion

• The best way to get vitamins is through food and not through supplements, but supplements can prevent deficiency diseases when dietary intake is inadequate. • Special populations may benefit from vitamin supplements, for example alcoholics, elderly patients, smokers, children, people with chronic disease and pregnant women. • Vegans need to obtain vitamin B12 from a source other than animal origin, for example brewer’s yeast, food fortified with vitamin B12 or a vitamin supplement. • Stress, smoking, infections and burns deplete vitamin C reserves and therefore higher doses of this vitamin are needed. Vitamin C is not stored in the body, thus it has to be taken regularly through the diet or supplements to maintain sufficient levels. Think about this … Processing starches can be good when this makes the nutrients in the food more available to the body, but most of the time starches are processed so much that they lose many of their nutrients. The staple foods of many South Africans include maize porridge and bread (both refined/ processed carbohydrates that do not contain many nutrients). To help prevent and address micronutrient deficiencies in the population, all bread flour and maize flour in South Africa must be fortified (or strengthened) with a specific vitamin and mineral mix (containing vitamin A, thiamine, niacin, pyridoxine, folate, riboflavin, iron and zinc). This regulation has been mandatory since 2003 and helps people take in more nutrients even if they do not have access to a variety of foods. Another intervention to help address micronutrient malnutrition in South Africa is the routine supplementation of certain vulnerable groups: • Children receive high-dose vitamin A drops every six months from the age of six months. • Pregnant women receive folate, iron and calcium supplementation during antenatal care.

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Table 20.1  Summary of vitamins Vitamin

Functions

Deficiency

Sources

Requirements*

Vitamin B1 (thiamine)

Appetite stimulation, blood building, circulation, digestion, growth, learning ability

Beriberi, affecting the neuromuscular and circulatory systems

Whole grains, oats, lean meat, liver, yeast

Males: 1.2 mg/day Females: 1.1 mg/day

Vitamin B2 (riboflavin)

Antibody and red blood cell formation, energy metabolism, cell respiration, maintenance of healthy skin, mucous membranes, cornea and vision

Ariboflavinosis (dermatitis, glossitis, photophobia)

Lean meat, poultry, fish, liver, milk and milk products, eggs, green leafy vegetables, whole grains

Males: 1.3 mg/day Females: 1.1 mg/day

Vitamin B3 (niacin)

Circulation, cholesterol level reduction, growth, hydrochloric acid production, metabolism (carbohydrate, protein, fat), sex hormone production, maintenance of normal skin, mucous membranes and nerve integrity

Pellagra

Lean meat, poultry, fish, yeast, peanuts

Males: 16 mg/day Females: 14 mg/day

Vitamin B5 (pantothenic acid)

Antibody formation, cortisone production, growth stimulation, stress tolerance, vitamin utilisation, conversion of carbohydrates, fats and protein

General failure of all body systems

Organ meats, mushrooms, avocados, eggs, yeast, milk, sweet potatoes

Males: 5 mg/day (AI) Females: 5 mg/day (AI)

Vitamin B6 (pyridoxine)

Antibody formation, digestion, deoxyribonucleic acid and ribonucleic acid synthesis, fat and protein utilisation, amino acid metabolism, haemoglobin production

Dermatitis, glossitis, seizures, anaemia

Meat, poultry, fish, vegetables, nuts, whole grain (especially wheat)

Males: 1.3 mg/day Females: 1.3 mg/day

Water soluble



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Vitamin

Functions

Deficiency

Sources

Requirements*

Vitamin B12 (cobalamin)

Blood cell formation, cellular and nutrient metabolism, iron absorption, tissue growth, maintenance and function of bone marrow, gastrointestinal system and nerve cells

Pernicious anaemia

Organ meats, meat, milk, eggs, fish, cheese

Males: 2.4 µg/day Females: 2.4 µg/day

Vitamin C (ascorbic acid)

Collagen production, digestion, fine bone and tooth formation, iodine conservation, healing promotion, red blood cell formation, infection resistance

Scurvy

Guavas, citrus fruits, paw-paw, tomatoes, sweet peppers, potatoes, cabbage. Exposure of cut surfaces to air, prolonged soaking and overcooking will decrease the vitamin C content dramatically

Males: 90 mg/day Females: 75 mg/day

Biotin

Cell growth, fatty acid production, metabolism, vitamin B utilisation, maintenance of skin, hair, nerve and bone

Anorexia, fatigue, depression, dry skin, heart abnormalities

Eggs, organ meats, legumes, yeast, milk and nuts

Males: 30 µg/day (AI) Females: 30 µg/day (AI)

Folate

Red blood cell formation, nucleic acid formation, cell growth and reproduction, hydrochloric acid production, liver function, protein metabolism

Megaloblastic macrocytic anaemia, fatigue, depression, neural tube defects, homocystenaemia

Liver, mushrooms, green leafy vegetables, lean beef, potatoes, whole grains, legumes, citrus fruits

Males: 400 µg/day Females: 400 µg/day



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Vitamin

Functions

Deficiency

Sources

Requirements*

Vitamin A (retinol)

Body tissue repair and maintenance, infection resistance, bone growth, nervous system development, cell membrane metabolism and structure

Hyperkeratosis, decreased immunity, night blindness, keratomalacia and xeropthalmia

Green leafy vegetables, yellow/ red/orange vegetables, edible yellow and orange parts of fruits and milk products, organ meats, egg yolk, fish, enriched margarine. Vitamin A in excess can be toxic, so do not overdo supplements

Males: 900 µg/day Females: 700 µg/day

Vitamin D (calciferol)

Calcium and phosphorus metabolism (bone formation), myocardial function, nervous system maintenance, normal blood clotting

Rickets

Exposure of skin to the ultraviolet rays of the sun, fish liver oil, fatty fish, bone meal, egg yolks, organ meat, butter, enriched margarine

Males: 5 µg/day (AI) Females: 5 µg/day (AI)

Vitamin E (tocopherol)

Aging retardation, anticlotting factor, diuresis, fertility, lung protection (antipollution), male potency, muscle and nerve cell membrane maintenance, myocardial perfusion, serum cholesterol reduction

Red blood cell haemolysis, oedema, skin lesions

Dark green vegetables, fruits, nuts, organ meat, eggs, vegetable oils, wheat germ, maize, legumes, unrefined cereal products, butter

Males: 15 mg/day Females: 15 mg/day

Fat soluble



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Vitamin

Functions

Deficiency

Sources

Requirements*

Vitamin K (menadione)

Liver synthesis of prothrombin and other blood-clotting factors, participates with vitamin D in the synthesis of bone protein

Haemorrhaging

Green leafy vegetables, sunflower oils, yoghurt, liver, molasses, broccoli, Brussels sprouts, dairy products

Males: 120 µg/day (AI) Females: 90 µg/day (AI)

* Recommended daily allowance (RDA) for persons older than 14 years, unless indicated otherwise (ie adequate intake or AI).

Minerals Minerals are simple inorganic substances that are widely distributed in nature and found in all body fluids and tissues. They play a role in promoting growth and maintaining health. Macrominerals are needed by the body in large amounts, while microminerals are needed by the body in small amounts. They are present in foods and are not sensitive to heat in cooking, but some may be lost in the cooking water as they are water soluble. Functions of minerals

Minerals have many roles in the body, such as providing structure to body tissues and regulating body processes. (See Table 20.2 for the major functions and food sources of minerals.) A disruption of the body’s balance in any one of these minerals can be life threatening. Digestion of minerals

Minerals must be digested in the gastrointestinal tract by enzymes that split large units into smaller ones (hydrolysis). The smaller units are then absorbed from the small intestine and transported to the liver through the portal vein system. Metabolism of minerals

Each mineral is metabolised independently of the others according to body need. The process differs for each mineral.

Clinical alert! Calcium and sodium are the minerals that cause the most health concerns. Less than optimal amounts of calcium increase the risk of osteoporosis, and excess sodium intake can increase the risk for hypertension. People who take calcium supplements should remember the following: • Do so in moderation – if doses higher than 500 mg are needed, the supplement should be spread throughout the day.

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• Calcium carbonate is best absorbed with food. • Calcium citrate is best absorbed on an empty stomach. Avoid taking calcium citrate with iron as calcium can interfere with iron absorption. • Constipation is a common adverse effect of calcium supplements – drink adequate fluids to reduce this risk. • Calcium supplements should not be taken to replace dietary intake of calcium.

To limit the intake of too much sodium use salt and foods high in salt sparingly: • Choose fresh foods rather than processed foods (eg fresh or frozen vegetables/fish rather than tinned). • Read food labels to avoid or limit foods that contain too much sodium. Compare labels of different brands of similar items to find the product with the lowest sodium content. • Avoid processed foods such as sausage, viennas, polony, bacon, biltong (dried meat) and droë wors (dried sausage), chips, savoury biscuits and tinned foods. • Limit the use of seasoning salt, stock cubes and soup powders, sauces and salad dressings. Rather use herbs, spices, garlic, chilli, curry, lemon juice or vinegar to flavour food. • Taste food before adding salt. • Be aware that high-sodium foods may not taste salty. • Limit intake to 2 g sodium or 5 g salt per day. Table 20.2  Summary of minerals Mineral

Functions

Deficiency

Sources

Requirements*

Calcium

Blood clotting, bone and tooth formation, cardiac rhythm maintenance, cell membrane permeability, muscle growth and contraction, nerve impulse transmission

Osteoporosis, stunted growth in children, brittle fingernails, heart palpitations, insomnia, muscle cramps, hypertension

Milk and milk products, green leafy vegetables, legumes, tinned fish (eaten with the bones)

Males: 1 000 mg/ day (AI) Females: 1 000 mg/ day (AI)

Chloride

Fluid, electrolyte, acid–base and osmotic pressure balance, component of HCl in the stomach (digestion)

Disturbance in acid–base balance

Salt

Males: 2.3 g/ day (AI) Females: 2.3 g (AI)

Macrominerals



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Mineral

Functions

Deficiency

Sources

Requirements*

Magnesium

Acid–base balance, metabolism, protein synthesis, muscle relaxation, cellular respiration, nerve impulse transmission

Confusion, disorientation, nervousness, irritability, tremors, muscle spasms, rapid pulse, neuromuscular dysfunction

Green leafy vegetables, nuts and seeds, seafood, cocoa, whole grains, legumes, unrefined cereals (eg oats)

Males: 400 mg/day Females: 310 mg/day

Phosphorus

Bone and tooth formation, cell growth and repair

Appetite loss, fatigue, irregular breathing, nervous disorders, muscle weakness

Eggs, fish, whole grains, meats, poultry, milk and milk products, nuts and seeds. Absorption is dependent on vitamin D

Males: 700 mg/day Females: 700 mg/day

Potassium

Muscle contraction, nerve impulse transmission, rapid growth, acid–base balance, osmotic pressure balance

Muscle weakness, paralysis, anorexia, confusion, weak reflexes, slow irregular heart beat

Meat, chicken, fish, potatoes, sweet potatoes, tomatoes, spinach, mangoes, bananas, citrus fruit

Males: 2 000 mg/ day Females: 2 000 mg/ day

Sulphur

Collagen synthesis, vitamin B formation, enzyme and energy metabolism, blood clotting

None

Meat, poultry, fish, eggs, dried beans, broccoli, cauliflower

Males: none Females: none

Growth (in children), haemoglobin production, immune function, cellular respiration,

Hypochromic microcytic anaemia, pallor, fatigue, koilonychia (brittle, concaveshaped nails),

Liver, seafood, red meat, chicken, fortified maize meal and bread, enriched breakfast

Males: 8 mg/day Females: 18 mg/day

Microminerals Iron



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Mineral

Functions

Deficiency

Sources

Requirements*

oxygen transport

constipation, respiratory problems

cereals, green leafy vegetables, dried fruit, eggs, legumes, nuts

Zinc

Wound healing, immune function, carbohydrate digestion, metabolism, transport of vitamin A, prostate gland function, reproductive organ growth and development

Growth retardation, delayed sexual maturation, poor wound healing, skin disorders, immune deficiency, fatigue, taste loss, poor appetite

Liver, meat, seafood chicken

Males: 11 mg/day Females: 8 mg/day

Fluoride

Bone and teeth formation (tooth enamel)

Dental caries

Fluoridated drinking water, seafood

Males: 3.8 mg/day (AI) Females: 3.1 mg/day (AI)

Copper

Bone formation, hair and skin colour, healing processes, haemoglobin and red blood cell formation, mental processes, iron metabolism

General weakness, impaired respiration, skin sores, bone disease

Organ meats, seafood, nuts, legumes, dried fruit

Males: 900 µg/day Females: 900 µg/day

Iodine

Energy production, metabolism, physical and mental development, thyroid hormone production

Poor cognition, mental retardation, endemic goitre (enlarged thyroid gland), cretinism

Salt (iodised), seafood

Males: 150 µg/day Females: 150 µg/day



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Mineral

Functions

Deficiency

Sources

Requirements*

Selenium

Immune mechanisms, cellular protection, fat metabolism

Rare

Seafood, organ meat, meat, chicken, eggs, whole grains

Males: 55 µg/day Females: 55 µg/day

Manganese

Enzyme activation, carbohydrate and lipid metabolism, growth and reproduction, formation of connective and skeletal tissue, vitamin B1 metabolism, vitamin E utilisation

Ataxia, dizziness, hearing disturbance/ loss, skeletal abnormalities, sterility

Whole grains, legumes, nuts, coffee, tea, bananas, egg yolks, green leafy vegetables, liver, soybeans

Males: 2.3 mg/day (AI) Females: 1.8 mg/day (AI)

Chromium

Carbohydrate lipid and protein metabolism, serum glucose maintenance

Insulin resistance

Liver, brewer’s yeast, potatoes, seafood, whole grains, meat, chicken, cheese

Males: 35 µg/day (AI) Females: 25 µg/day (AI)

* Recommended daily allowance (RDA) for persons older than 14 years, unless indicated otherwise (ie adequate intake or AI).

Water/fluid A continuous supply of clean, safe water is one of our most basic nutritional needs as a person can survive no longer than a few days without water. Water makes up to 50–80% of a person’s total body weight and is essential in ensuring a balanced distribution of fluids to all body cells. Body water contains dissolved substances (solutes) that are necessary for physiological functioning. Solutes include electrolytes, glucose, amino acids and other nutrients. Functions of water/fluid in the body: • It serves as a medium for all biochemical reactions in the body. • It serves as a lubricant, for example within the eyes and joints. • It acts as a solvent for minerals, vitamins, glucose and other small molecules. • It gives structure and shape to cells, and helps form the structure of large molecules, for example protein and glycogen.

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• It helps to regulate body temperature (eg evaporation of sweat from the skin surface). • It aids nutrient digestion and absorption. • It transports nutrients to cells, and carries waste products away from them through urine, faeces and expiration.

Sources of water/fluid Liquids are the only water sources that meet the body’s fluid needs but solid foods and metabolic water also contribute to total fluid intake. In an average diet, solid foods supply about 700 to 1 000 ml of water per day. The metabolism of carbohydrates, fats and proteins produces about 240 ml of water per day. To maintain fluid balance, a person’s fluid intake should equal their fluid output. On average, an adult loses about 1 450 to 2 800 ml of water daily through sweating, breathing and urinating. These losses should be replenished by drinking 6–8 glasses of clean, safe water every day. The body needs extra water when sweating a lot (during strenuous activity or hot weather) and with fever, diarrhoea or vomiting.

Sugar-salt solution During diarrhoea and vomiting, it is possible for the body to become dehydrated when too much fluid is lost. This dehydration is dangerous, and can be life threatening in young children. Teach caregivers how to treat dehydration at home with a sugar-salt solution. Take 1 litre of boiled cooled water, and add 8 level teaspoons of sugar and half a level teaspoon of salt. Give frequent sips of the sugar-salt solution from a cup after every loose stool. If vomiting occurs, wait 10 minutes and then start again, but more slowly.

Factors affecting nutrients in food There are several factors that affect the nutrients in food. These include genetics and growing conditions, the bioavailability of nutrients, and the handling and processing of food.

Genetics and growing conditions The nutrient content of plant foods is affected by the plant’s genetic makeup, maturity and the growing conditions. Factors such as temperature, amount of sunlight, amount of water and type of soil can influence how well a plant grows and how nutritious it will be. Studies show that organically grown foods are nutritionally identical to inorganically fertilised foods. Nutrients in animal foods tend to be less variable; they are influenced by breed, age of the animal and type of feed received. Bioavailability of nutrients The bioavailability of nutrients in a particular food refers to the extent to which nutrients can be readily used by the body. It depends on the form in which the nutrients are present in that particular food. Minerals and other nutrients may interact and affect each other’s bioavailability (eg milk products and tea hinder the absorption of iron from food while citrus enhances it). It is recommended to consume a mixed diet with moderate amounts of a variety of foods in order to obtain maximum bioavailability and avoid potentially detrimental nutrient concentrations. 386

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Handling and processing of food Harvesting, storage and processing methods also affect nutrients. Time and temperature are key factors here. Cool conditions and short storage time generally lead to better nutrient retention. Carbohydrates, proteins and saturated fats undergo little change in ordinary cooking processes. During severe processing where any part of the food is discarded, loss of protein, fat, carbohydrate, vitamins and minerals will occur. Of all the nutrients, vitamins are the most unstable as they are easily destroyed by cooking temperatures or lost in water used for boiling food. This is why it is best to cook vegetables in a small amount of water and for a short time.

Nutrition in relation to health Most countries have established nutrition standards or guidelines for major nutrients in order to maintain healthy populations. In South Africa we most commonly use the recommended dietary allowance (RDA) when referring to nutrients and the South African Food-Based Dietary Guidelines when referring to foods.

Recommended dietary allowance (RDA) The RDA tells you what percentage of your daily nutritional requirements the food contains, based on a diet of around 8 400 kilojoules per day. The values for RDAs are different for different age groups and genders. Producers of food are required by law to list the contents of their products on the labels. If you spot an RDA percentage of more than 20% for a specific vitamin or mineral, this product is a particularly good source of that nutrient. South African Food-Based Dietary Guidelines The South African Food-Based Dietary Guidelines are short, positive messages that aim to teach the population how to make food and beverage choices that will meet their nutrient needs and lower their risk for developing non-communicable diseases. The value of these messages are that they were designed specifically for South Africans so they take into account the dietary patterns of the local populations, and aim to address relevant public health concerns of both over- and undernutrition. These guidelines are also food based and not nutrient based, so they are easier for the general population to understand and apply. The Department of Health has also designed a visual South African Food Guide. It illustrates the different food groups that should be eaten regularly in various circles. The size of the circle shows the proportion that each group should contribute to a person’s diet. Unlike many other visual food guides, it does not include items like sugar, sweetened food or drinks, and salt. 387

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The South African Food-Based Dietary Guidelines for South Africans • Enjoy a variety of foods. • Be active! • Make starchy foods part of most meals. • Eat plenty of vegetables and fruit every day. • Eat dry beans, split peas, lentils and soya regularly. • Have milk, maas or yoghurt every day. • Fish, chicken, lean meat or eggs can be eaten daily. • Drink lots of clean, safe water. • Use fats sparingly. Choose vegetable oils rather than hard fats. • Use salt and foods high in salt sparingly. • Use sugar and foods and drinks high in sugar sparingly. Enjoy a variety of foods Eating does not only serve to satisfy physical hunger but is an important part of family life, social events and celebrations. Enjoying a variety of foods helps to keep meals interesting and provides the body with different nutrients needed for health. Variety means choosing foods from two or more groups at each meal (eg eating maize porridge with milk), enjoying different foods from each group (not buying the same vegetables every week) and preparing foods in different ways (eg boiling carrots, adding them to stews or eating them raw). Be active! Regular physical activity has many benefits, including increased blood supply to the body; achieving and maintaining a healthy body weight; decreased risk for development of non-communicable diseases; stronger bones; relief from anxiety; and increased wellbeing. Aim to be physically active for 30–45 minutes every day. This can include many different activities and does not need to be expensive. Cleaning the house, working in the garden, going for a brisk walk or taking the stairs instead of the lift are all examples of ways to be active throughout the day. Make starchy foods part of most meals Starchy foods include maize porridge, oats, rice, pasta, samp, potatoes and bread. Starch is the main source of energy for the body and provides essential micronutrients and fibre, especially when unrefined or whole grain options are chosen. Starchy foods are usually readily available and affordable. For this reason maize and bread flour in South Africa has been fortified to provide extra vitamins and minerals for people whose diets are lacking in variety. It is best to choose starchy foods that have no or little added sugar, salt and fat. Eat plenty of vegetables and fruit every day Vegetables and fruit provide the body with many vitamins and minerals and are a good source of fibre and water. They also help to add flavour, colour, texture and variety to meals. These foods can be eaten both raw and cooked, but should always be washed before use. When cooking vegetables, use only a little water, cook them for a short time and eat them as soon as possible, otherwise the vitamins and minerals are lost. Also do not add a lot of sugar, salt or fat to vegetables. Fruit and vegetable juices are not recommended as a frequent replacement as these contain little fibre and large amounts of sugar.  ➙

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Rather choose vegetables and fruit that are locally available and in season as these are generally fresh and more affordable, or plant vegetables at home or in a community garden. Eat dry beans, split peas, lentils and soya regularly These foods contain protein which means that they can be used instead of animal protein (chicken, fish, lean meat or eggs) or with animal protein to extend meals. Dry beans, peas, lentils and soya also contain fibre, which helps to decrease the risk for non-communicable diseases. Eat these foods regularly by adding them to stews, soups, curries, rice or samp. Have milk, maas or yoghurt every day Milk, maas and yoghurt are good sources of protein and calcium. As milk is an animal product and contains saturated fat, it is best to choose products that are low fat or fat free (skimmed). Also choose products with little or no added sugar. Fish, chicken, lean meat or eggs can be eaten daily These are animal foods and good sources of protein. Chicken, fish, meat and egg yolks contain iron, vitamin B12 and zinc, which are important for the prevention of anaemia. Although these foods can be eaten daily they do not have to be. Many South Africans eat too much of these foods (especially meat, chicken and eggs) and this is contributing to the increased prevalence of non-communicable diseases. When eating these foods, choose wisely, prepare the foods in a healthy way and eat sensible portions. When eating chicken or meat, choose cuts that are not very fatty and remove all visible fat before cooking. These foods contain saturated fat and cholesterol, which increases the risk for non-communicable diseases. Processed products such as sausages, viennas, polony, salami and bacon contain a lot of fat and salt, and should be eaten only occasionally. When preparing chicken, fish, meat or eggs, it is best not to fry them in oil but rather to steam, grill, boil, stew or braai them. Drink lots of clean, safe water Body fluid is continuously lost through sweating, breathing and urinating, and should be replenished by drinking 6–8 glasses of clean, safe water every day. The body needs extra water when sweating a lot (during strenuous activity or hot weather) and with fever, diarrhoea or vomiting. Use fats sparingly. Choose vegetable oils, rather than hard fats Fats provide energy, help to build cells and are needed for absorption of fat-soluble vitamins A, D, E and K. However, too much fat can lead to weight gain and is associated with increased risk for the development of non-communicable diseases The amount and type of fat are both important: most animal fats (except for the fat in fish) contain a lot of saturated fat, while most plant oils contain unsaturated fat that can decrease harmful cholesterol in the body. Eating fats sparingly means using a little of the best choices of fats at a time. Use salt and foods high in salt sparingly Eating too much salt and foods containing salt can increase the risk for coronary heart disease and stroke by raising the blood pressure of people who are genetically at risk. Although salt is needed to help regulate fluids in the body, eating a variety of foods will provide enough salt so it is unnecessary to add extra salt to food. If salt is added, use very little at a time, either during cooking or at the table.  ➙

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Also be aware of foods that have hidden salt such as seasoning salt, stock cubes and soup powders, sauces, processed meat, chips, savoury biscuits and tinned foods. Use sugar and foods and drinks high in sugar sparingly Sugar contains energy but no other nutrients to build or strengthen the body. Eating too much sugar or sugary foods and drinks can cause tooth damage and weight gain. In children it can also spoil their appetite and cause them not to eat the nutritious foods they need to grow. Using sugar sparingly means using as little as possible, only a few times per day (eg add 1–2 teaspoons of sugar to porridge or spread jam thinly on bread, but do not make a habit of using sugar with every meal). This includes sugary foods and drinks such as sweets, cakes, biscuits, ice cream, syrup, jam, fizzy drinks and cool drinks.

Nutrition through the life cycle Nutrition plays a major role throughout life. Each stage of life has specific nutritional needs to ensure optimum functioning of the body.

Nutrition during pregnancy and lactation A pregnant woman has increased nutrient needs because of her increased body weight and the growth of her foetus. The amount of extra nutrition required varies from person to person, depending on a woman’s nutritional status before pregnancy, her level of activity and her general living conditions. The health of a pregnant woman has a great impact on the health of her child, not only for the time of gestation but also for the rest of her child’s life. The amount of weight gained during pregnancy indicates whether a women’s diet is adequate or not, so it is important to consume enough nutrients to ensure good weight gain. If a woman has a poor nutritional status and gains too little weight, her child will not receive enough nutrients. The rates of low birth weight infants (< 2 500 g) are higher in women who gain too little weight during pregnancy. Currently the incidence of low birth weight in South Africa is 15.5% (District Health Information System 2010). Another problem with gaining too little weight during pregnancy is that this can increase the child’s risk of developing non-communicable diseases such as heart disease, type 2 diabetes and hypertension later in life. Being overweight or obese (having a BMI > 25) also has risks related to pregnancy such as gestational diabetes, pregnancy-induced hypertension, premature birth and the increased possibility of caesarean section. It can also result in the birth weight of the baby exceeding 4 000 g. Weight gain should range from 0.3 kg (for overweight women) to 0.5 kg or more (for underweight women) per week during the second trimester. The World Health Organization found that the energy and nutrient needs of HIVpositive pregnant women are the same as those who are HIV negative (Du Plessis, Labuschagne & Naude 2008, citing WHO 2003). HIV infection does, however, increase the risk of maternal malnutrition, which can lead to morbidity and mortality of the mother and/or child. It is also well known that HIV can be transmitted from a mother to her child during pregnancy if adequate steps to prevent this are not taken.

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Some of the nutrition-related problems during pregnancy are the following: • Anaemia • Nausea and vomiting/hyperemesis gravidarum • Heartburn • Constipation • Pica • Gestational diabetes • Pregnancy-induced hypertension. Anaemia

In South Africa, 16–26% of pregnant women have anaemia (Du Plessis et al 2008) due to deficiencies of iron, vitamin B12 and/or folate, genetics and infections. Iron deficiency is a risk factor for maternal mortality, and is responsible for 20% of maternal deaths globally per year (Department of Health 2013). Folate deficiency can also lead to neural tube defects and reduced growth in the foetus. In South Africa, pregnant women routinely receive both iron and folate supplements, resulting in a 73% reduction of anaemia at term. Pregnancy-induced hypertension

Pregnancy-induced hypertension can be caused by obesity, excessive weight gain during pregnancy, genetics, age and chronic hypertension in previous pregnancies. Severe forms of pregnancy-induced hypertension are a serious threat to the survival of both the mother and foetus, and the only treatment is immediate delivery. Hypertension contributes to 15.7% of maternal deaths in South Africa (MNCWH). Although all the risk factors cannot be controlled, promoting a healthy pre-pregnancy weight and healthy weight gain during pregnancy could prevent the onset of this problem. All pregnant women should also receive routine calcium supplementation (800–1 000 µg) to prevent pre-eclampsia.

Clinical alert! Avoiding harmful substances during pregnancy and lactation Alcohol All alcohol should be avoided during pregnancy because it is able to cross the placental membrane and affect the developing foetus. If a pregnant woman drinks alcohol during pregnancy, her child can be affected by foetal alcohol spectrum disorders which include abnormalities in the child’s body structure, behaviour and cognitive function. When children are severely affected, they are referred to as having foetal alcohol syndrome (FAS). Alcohol can also be passed through the breast milk, where it can interfere with the child’s brain development. The damage caused by alcohol intake during pregnancy and lactation is irreversible, and nurses should strongly emphasise this reality to all community members.  ➙

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Smoking Smoking during pregnancy reduces the amount of oxygen supplied to the foetus. The negative effects of smoking during pregnancy are dose dependent, and include reduced birth weight, increased risk of preterm delivery, impaired intellectual development and foetal nicotine addiction. Smoking is also harmful to the child after birth because the child will be exposed to the cigarette smoke in the environment (causing respiratory problems) and nicotine in the breast milk. Caffeine Consuming too much caffeine can possibly cause miscarriages in the first trimester. The current recommendation is that pregnant women should have no more than four 150 ml cups of caffeine-containing drinks such as coffee, tea, soft drinks and energy drinks per day. Chocolate, some energy bars and some medications also contain caffeine and should be used with caution. Food safety Increased progesterone levels during pregnancy decrease a woman’s ability to resist infectious diseases, making her more prone to food-borne infections. These can have serious consequences, including spontaneous abortion, stillbirth, mental retardation, blindness, seizures and death.

Infant nutrition The first 1 000 days of life, from conception to the age of two years, represent a unique window of opportunity to invest in the health of a human being. Appropriate feeding practices are essential for the survival, optimal nutritional status, growth and development of infants and young children. Appropriate feeding practices include starting breastfeeding within one hour after birth, breastfeeding exclusively for the first six months of life and introducing nutritionally adequate and safe complementary foods at six months while continuing with breastfeeding for two years and beyond (Department of Health 2013: 39). Exclusive breastfeeding for six months and continued breastfeeding up to one year may prevent 13% of all deaths in children younger than five years in countries with a high under-five mortality rate, far outweighing the number of deaths that can be prevented by any other single preventive action. This is why the protection, promotion and support of breastfeeding is considered to be a key child survival strategy (Department of Health 2013). Although breastfeeding is a common practice throughout the developing world, exclusive breastfeeding is rare. In South Africa mixed feeding of children under six months of age is a common practice, with only 26% of children aged 0–6 months being exclusively breastfed (Department of Health 2013: 45). The current South African Infant and Young Child Feeding policy states: ‘There is considerable evidence that exclusive breastfeeding for six months confers many benefits over mixed feeding’ (Department of Health 2013: 39). The benefits for both mother and child are summarised in Table 20.3. There are various reasons why mothers struggle with exclusive and ongoing breastfeeding. These include the perception of insufficient milk, misinformation, fear of 392

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HIV transmission, marketing of breast milk substitutes, returning to work, pressure from family members and cultural practices. Mothers need knowledge and much support to continue with breastfeeding in spite of these challenges. Healthcare workers should do all they can to protect, promote and support breastfeeding in South Africa. Table 20.3  Benefits of exclusive breastfeeding For the mother • Helps to achieve a healthy weight • Strengthens bonding with the infant • Decreases post-partum depression • Can prevent development of cancer in later life • Prolongs birth intervals through postpartum amenorrhoea • Less stress about inadequate milk supply for the child • More economical. For the child • Provides the child with all the needed nutrients • Strengthens the child’s immunity and resistance to disease • Prevents infections (such as diarrhoea and pneumonia) and deaths caused by these infections • Strengthens bonding with mother • Improves cognitive function • Reduces risk of developing obesity and chronic diseases later in life. Breastfeeding in the context of HIV

In 2011, the National Minster of Health, Dr Aaron Motsoaledi, declared that South Africa had adopted the 2010 WHO Guidelines on HIV and Infant Feeding, and recommended that all HIV-infected mothers should breastfeed their infants and receive anti-retroviral therapy (ART) to prevent transmission (Tshwane Declaration 2011). Availability of lifelong ART for pregnant women and low-dose nevirapine for HIV-exposed infants strengthens arguments for promoting exclusive breastfeeding as the best choice for South African women. Exclusive breastfeeding protects the intestinal lining of the stomach, which prevents the passage of HIV and causes fewer breast problems (which decreases the risk of transmission). Complementary feeding (6–12 months)

Nutritionally adequate and safe complementary foods should be introduced at six months of age accompanied by the continuation of breastfeeding until the age of two years or beyond. If complementary foods are introduced too early when the digestive tract is immature, there is the risk of diarrhoea and allergies. Introducing complementary foods too late could lead to under-nutrition, decreased immunity and the reluctance to try new flavours and textures. Soft porridge is often the first food to be introduced to the child, followed by vegetables and fruit. Allow the child to get accustomed to the taste and texture of one new food at a time and look out for any allergies or intolerances should they occur. It is not necessary for caregivers to buy commercial infant foods as it is much more

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economical and healthier to prepare the food at home. Caregivers should not add sugar, salt or spices to infant food. Locally available animal foods should be given to infants to supplement the iron in breast milk. This includes egg yolk, minced meat, soft chicken, chicken livers, etc. Young children should also be offered clean, safe water regularly.

Nutrition during childhood Good nutrition is very important for a child’s growth and development. In South Africa there are major public health concerns regarding the nutritional status of local children. In spite of the country’s high per capita income, stunting (indicating long term under-nutrition) has increased from 23.4% in 2008 to 26.5% in 2013. Overweight and obesity are also a cause for concern with overweight in young children increasing from 10.6% in 2005 to 18.2% in 2013. The prevalence of obesity has remained quite constant, currently at 4.7%. Although there has been an improvement in both the iron and vitamin A status of children over the past decade, anaemia still affects 10.7% of children while the prevalence of vitamin A deficiency at 43.6% is a public health problem (SANHANES 2013). There are various policies and programmes in place to address problems (such as the national school feeding programme or routine vitamin A supplementation) but some of them are poorly implemented or may have inadequate coverage. The problem of under-nutrition is also more than just an inability to take in enough food as poor social circumstances, poverty, lack of education, gender inequality and many other factors also play a role. These challenges are complex and require that different sectors work together effectively to improve the nutrition situation for children in South Africa. This includes the healthcare sector and the nurse is a valuable person who can make a significant difference for the people in his/her care. One of these ways is through appropriate nutrition education. Encourage children to enjoy a variety of foods as this will allow them to get different nutrients from different foods and to enjoy a greater variety of foods when they are older. Feed children five small meals per day, making starchy foods the basis of most meals and giving them plenty of vegetables and fruit every day. Give foods rich in iron, vitamin A and vitamin C. Children can eat chicken, fish, eggs, beans, soya or peanut butter every day but they need to drink milk every day. This can be breast milk if the mother has continued breastfeeding or full-cream cow’s milk or sour milk (500 ml per day). If children have sweet treats or drinks, offer small amounts with meals and remember to regularly offer clean, safe water. Also encourage children to play and be active every day. Children can be encouraged to eat by themselves by offering them finger foods in shapes and sizes that are easy to handle. Offer a variety of textures and flavours so that they will enjoy a variety of foods when they are older. Children often respond well when allowed to participate in food preparation and when new foods are gradually introduced in small portions, served along with familiar food. Remember that children have small stomachs (about the size of their fist), so they will need healthy snacks throughout the day. If they are refusing to eat it may be because they are too inactive or too tired, or have been snacking or drinking before meals. Rather avoid giving drinks 30–60 minutes before meals.

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Oral health

Tooth decay is the most common chronic disease of childhood. The prevalence of dental caries in South Africa is about 50% in children aged 4–5 years (Swart & Dhansay 2008, citing Van Wyk et al 2004). This is caused by poor oral hygiene, vitamin and mineral deficiencies during the time of tooth formation (even as early as six weeks’ gestation when tooth development begins) and inappropriate use of bottles. If children are put to bed with a bottle, their teeth bathe in the liquid for a long period and the sugar in the liquid (whether it be milk, fruit juice or sweetened tea) causes damage to the teeth. Children should not receive fruit juice and soft drinks often and when given they should be diluted with water and given in a cup rather than a bottle.

Nutrition during adolescence The need for nutrients and energy increases during the growth spurt in adolescence but specific needs will differ depending on nutritional status, activity, lifestyle and living conditions. Adolescent eating patterns often become adult practices, so adolescence provides a unique opportunity for health promotion and nutrition education. Healthy habits can be formed during this time before poor habits become fixed and difficult to change. It is accepted that adolescents generally tend to have poor eating habits. This is due to increased snacking on food that contains large amounts of energy but very few nutrients (eg chips or sweets), skipping meals, increased intake of fast foods and soft drinks, eating meals away from home (eg due to sport commitments or socialising with friends) and an intense concern about their physical appearance (often influenced by the media and the latest fashion). It is common for adolescents to experience dissatisfaction with their bodies. This leads to eating habits and exercise behaviours that are aimed at weight loss or weight gain and building muscle mass. Some of these practices can be dangerous to their health (eg the use of steroids or when restrictive eating habits become eating disorders). At the same time, over-nutrition is also a major problem, with 17% of high-school children being overweight or obese, according to the National Youth Risk Behaviour Study (Reddy et al 2003). Prevention of malnutrition (under- and over-nutrition) should include both females and males, with a focus on decreasing body dissatisfaction, critically evaluating cultural norms, understanding physical development during puberty and increasing knowledge about good nutrition. Many adolescents also engage in high-risk behaviour such as cigarette smoking, alcohol and substance abuse, unprotected sexual activities (causing unplanned pregnancies and/or sexually transmitted diseases). These behaviours among the youth are also a great cause for concern as it directly impacts their health. Nutrition in adulthood While underweight does not seem to be a serious problem among South African adults, overweight and obesity are a major cause for concern. The prevalence of these conditions is worsening and is significantly higher in females than in males, with 24.8% of females being overweight, while 39.2% are obese (SANHANES 2012). It was also found that 20.2% of males and 68.2% of females had a waist circumference that increased their risk for metabolic complications. Overweight and obesity lead to chronic 395

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non-communicable diseases that affect the quality of life and life expectancy of many individuals while placing a great burden on the healthcare system. Weight gain occurs when the intake of energy from food is more than the energy that is used (eg eating too much fatty food while being inactive). In South Africa there is a definite link between urbanisation and the development of obesity, often referred to as the nutrition transition. Traditional foods (which are normally low in fat and rich in fibre) are replaced by a more Western-style diet that contains a lot of meat, dairy products, fat and/or oil, refined foods and sugar. Physical activity also decreases as people move from an environment where they were doing physical work (like farming) to an environment where they make use of transport, have sedentary jobs, remain indoors due to crime and violence, or generally lead inactive lives. The combination of the increased energy intake and decreased energy use causes an imbalance of energy and leads to the alarming weight gain that we currently see in our society. Many people from African cultures perceive that a bigger body shows that they are healthy, wealthy and well cared for. Some people are also fearful that if they do lose weight or maintain a healthy body weight, community members might think that they have HIV, AIDS or TB. It is important to treat those who are already overweight, and at the same time prevent those with a healthy weight from becoming overweight. A short-term solution is not adequate to change this issue in society. Programmes should aim to empower individuals/groups to take responsibility for making permanent lifestyle changes towards healthy dietary intake and physical activity through behaviour modification (Senekal, Mchiza & Booley 2008).

Nutrition in the elderly Population aging is occurring worldwide but life expectancy in sub-Saharan Africa is much lower than in other regions, and is decreasing, mainly due to AIDS-related deaths. In South Africa, life expectancy is currently 57 years for men and 60 years for women (WHO 2013). Good nutrition is essential for the health, independence and quality of life of older persons. Although the elderly need less energy (due to the decline in metabolic rate and decreased physical activity) they have increased nutrient needs and at the same time face many barriers to the attainment of good nutrition. Factors that lead to the malnutrition in the elderly can generally be grouped into three categories, namely social, physical/medical and psychological/emotional factors (see Table 20.4). Table 20.4  Factors causing malnutrition in the elderly Social

Physical/medical

Psychological/emotional

• Poverty • Isolation • Difficulty buying food • Difficulty preparing meals • Abuse/neglect by caregivers

• Decreased appetite • Chewing difficulties • Swallowing difficulties • Dry mouth • Decreased smell or taste • Poor eyesight • Physical disabilities • Weakness • Chronic disease or infection

• Loneliness • Depression • Bereavement • Cognitive impairment • Mental illness • Alcoholism

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On the contrary, overweight and obesity are also common problems in old age. The elderly experience changes in body composition (often due to physical inactivity) as their skeletal muscle mass decreases and their body fat increases. These changes, along with reduced function in certain organs, can increase the risk of developing many chronic diseases such as hypercholesterolaemia, atherosclerosis, insulin resistance, hypertension and type 2 diabetes. Being overweight also worsens arthritis and can impair physical mobility and respiratory function. There is inconsistent evidence regarding the consequence of weight change in old age on mortality outcomes, and weight loss may be detrimental to health. Weight management in older persons should therefore include increased physical activity and increased intake of nutrient-dense foods. Restricting food too much in this age group could compromise their intake of important nutrients and negatively influence the enjoyment of social aspects surrounding food. Most nutrition services for older people are provided by non-governmental organisations that aim to support older persons in the community. Some of these programmes are subsidised by the Department of Health and/or the Department of Social Development, and include home-based care and community-based senior clubs. Services provided at senior centres usually include healthcare, counselling and recreational or empowerment activities in addition to the provision of meals.

Nutritional guidelines for people living with HIV/AIDS and/or TB HIV/AIDS is the largest single cause of death in South Africa, and the burden of TB is equally disturbing (Naude, Labuschagne & Labadarios 2008). Although there are drugs that effectively control HIV/AIDS and cure TB, the importance of good nutrition to improve the health and quality of life of people living with HIV, AIDS and/or TB should not be ignored. An optimal nutritional status causes the immune system to function well, which is why nutritional deficiencies are so closely linked with a reduced ability of the immune system to defend the body against infections. When a person is malnourished, he or she is at greater risk of getting an infection, such as TB or HIV. On the other hand, having an infection can directly or indirectly lead to malnutrition, so malnutrition and infection exist in a vicious cycle, each making people more susceptible to the other. There are many factors contributing to malnutrition in people infected with HIV, AIDS and/or TB. They have increased energy needs due to the primary infection, secondary opportunistic infections and fever. They have decreased energy intake due to symptoms such as poor appetite, nausea or malabsorption. They can also have increased nutrient losses due to diarrhoea or vomiting. This can lead to weight loss and/or deficiencies in micronutrients, which can accelerate disease progression and mortality, and influence how effectively treatment works. Unfortunately many people living with HIV are also more at risk of developing noncommunicable diseases due to lipodystrophy (a side effect of ART) and/or the nutrition transition experienced in many communities.

Nutrition interventions People living with HIV, AIDS and/or TB have increased energy needs due to various factors, as discussed above. A report from the Academy of Science of SA states that the 397

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nutritional care of people infected with HIV and/or active TB should focus on adequate diversified diets including locally available, affordable and traditional foods. They should also receive fortified foods as well as macro- and micronutrient supplements at safe levels (Academy of Science of SA 2007). In children infected with HIV, AIDS and/or TB, the provision of adequate energy and nutrients is very important, because such children have increased requirements as a result of both growth and the infection. Children have small stomachs, so meeting their increased requirements can be challenging, but careful planning can ensure adequate nutrient intake. Growth monitoring is of the utmost importance to ensure early detection of malnutrition. Good nutrition cannot directly prevent the spread of these infections or cure them, but it can improve the individual’s health, quality of life and response to drug treatment. There is no single food or nutrient that can alter the course of these diseases or cure malnutrition, so people are encouraged to enjoy a variety of foods. People infected with HIV/AIDS and/or TB are specific target groups of the Department of Health’s Nutrition Therapeutic Programme. They will receive nutritional supplements in the form of enriched porridge and/or energy drinks from their primary healthcare facility if their BMI is below the determined cut-off point. Micronutrient supplementation

A good multivitamin and mineral supplement (that provides 50–150% of recommended daily intake) is advisable, especially because it is unlikely that an infected person will be able to meet the increased requirements for vitamins and minerals with food intake alone. It is important to remember, though, that micronutrient supplementation is useful only in combination with an adequate and well-balanced diet and can never replace the need for adequate food intake. Supplements should be taken with caution and only after consulting an expert health professional. Multivitamin supplementation (excluding vitamin A) in HIV-infected pregnant women reduces the risk of disease progression, AIDS-related mortality and adverse pregnancy outcomes. Pregnant and lactating women should not receive vitamin A because it possibly increases the risk of mother-to-child transmission of HIV and the risk of mortality of infants whose mothers are supplemented. Patients receiving isoniazid as part of their TB treatment should also receive 25 mg pyridoxine (vitamin B6) supplements per day, because isoniazid is an antagonist of pyridoxine and can cause a deficiency in the body. Children are not routinely supplemented unless they are receiving large doses of isoniazid (more than 10 mg per day). In this case they too should receive 25 mg of pyridoxine supplements per day. Complementary and alternative therapies

Some people living with chronic diseases such as HIV/AIDS may want to use complementary or alternative therapies (eg St John’s Wort, garlic, African potato) in the hope of improving or curing their condition. This could be motivated by desperation or by cultural beliefs. Although some substances may be harmless and even offer some benefit, others can be harmful and interfere with the effectiveness of antiretroviral therapy (ART). Healthcare workers should be well informed of the benefits and risks of local therapies in order to provide sound advice.

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Food safety and hygiene

People living with HIV, AIDS and/or TB are usually more vulnerable to contracting food-borne illnesses as their immune system is weakened. It is therefore important for them to follow basic food safety guidelines. • Practise good personal hygiene. Always wash hands thoroughly with soap and water (preferably warm water) before touching food, between touching raw and cooked food, after touching pets and other animals, after visits to the toilet and after sneezing or blowing the nose. Cover all wounds to prevent contamination when working with food. • Use clean, safe water. In South Africa it is generally safe to drink water from a tap. If water is sourced from a river or well, it should be boiled before use. If this is not possible, add one teaspoon (5 ml) of bleach to 25 litres of water. Mix it well and let it stand for two hours (or preferably overnight) before using it. Store it in a clean container with a lid or covered with a cloth. • Keep a clean kitchen. Wash all work surfaces and dishes/utensils with soap and water. Use kitchen cloths in the kitchen only, and disinfect cloths, sponges and scourers with bleach. Replace cracked crockery and scratched plastic containers/ boards as they are ideal hiding places for germs and are difficult to clean properly. • Shop safely. Buy food from a reliable person/place with good food-handling practices. Although buying in bulk may be cheaper, rather buy food in amounts that can be used before it spoils. Check the quality of foods and avoid dented/bulging cans, cracked eggs, and products that have passed their ‘sell by’, ‘best by’ or ‘use by’ dates, even if they still look good or the price has been marked down. • Enjoy safe foods. If unsure of where food comes from or how it has been prepared, it is safer not to eat it. Avoid products containing raw or undercooked meat or eggs, even in small amounts, including biltong (dried meat) and droë wors (dried sausage). Always cook meat, chicken, fish and eggs very well to kill bacteria. Only use pasteurised milk. Wash vegetables, fruit and eggs before use. Avoid eating mouldy fruit and cheese. • Handle and store food safely. Uncooked food should be kept separate from cooked food to avoid cross-contamination (from raw meats to other foods). Store cold foods in a fridge or freezer. Defrost foods carefully (in a fridge, microwave or a cool place away from direct sunlight) and not at room temperature as this allows for bacterial growth. Always keep food well covered to prevent flies and other insects from reaching it. Reheat left-over foods to a high temperature to destroy any bacteria. Another good resource for useful information is the South African National Guidelines on Nutrition for People Living with HIV, AIDS, TB and other chronic debilitating conditions.

Nutritional guidelines for people with non-communicable diseases In 2005, 60% of deaths in the world were due to non-communicable diseases (mainly heart disease, stroke, cancer, chronic respiratory diseases and diabetes). This is double the number of deaths for all infectious diseases (HIV/AIDS, TB, malaria), maternal and perinatal conditions, and nutritional deficiencies combined. The global burden

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of non-communicable diseases is enormous, but the common risk factors are largely modifiable, therefore action can be taken to reduce related morbidity and mortality (Medical Research Council 2012). Achieving and maintaining a healthy body weight should be an important goal in the treatment plan. Moderate weight loss of 5–10% of body weight in people who are overweight is associated with an improvement in blood glucose control, dyslipidaemia and blood pressure. Both the amount and type of food eaten as well as physical activity can help with weight loss. The South African Food-Based Dietary Guidelines and the South African Food Guide can be used as nutrition education tools while emphasising the most relevant messages for the person’s condition. People should be empowered with knowledge and skills to take responsibility for their health and be supported in their efforts to make decisions that will improve their health and quality of life.

Assessment of nutritional status Nutrition assessment is the process used to evaluate nutritional status, identify malnutrition and determine which individuals need nutritional support. Assessment will help to plan appropriate interventions for the patient and monitor results of the intervention to determine whether it is effective or not. There are four major assessment areas to determine a person’s nutritional status: A – Anthropometric measurements B – Biochemical or laboratory analysis C – Clinical evaluation D – Diet history.

Anthropometric measurements There are various different measurements that can be done, and often more than one measurement will be required to do a proper assessment (eg comparing a person’s weight with their height will provide much more information than taking only their weight). This information is most valuable when the measurements are accurate and are recorded over a period of time. Weight

Children from birth to two years of age should be weighed without clothing or nappies, sitting or lying down on a paediatric pan scale. Children older than two years and adults should be weighed in light clothing (removing jackets or jerseys) and without shoes. Length or height

Children from birth to two years of age who cannot yet stand are measured without shoes and head coverings, lying down by using a length board or mat. Children older than two years and adults are measured while standing without shoes or head coverings using a stadiometer or measuring rod. If they are unable to stand, an indirect method such as arm span, recumbent length or knee height can be used to determine their length by using specific calculations.

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Head circumference

Head circumference is useful in assessing severe growth disorders and intracerebral abnormalities in children. These measurements are only taken at 14 weeks and 12 months and compared to expected values. Mid-upper arm circumference

The arm contains both subcutaneous fat and muscle, so a decrease in the mid-upper arm circumference could indicate a decrease in either or both. The mid-upper arm circumference is a quick, easy, non-invasive tool to assess nutritional status, and can help to evaluate patients who cannot be weighed (eg a child with cerebral palsy) or someone whose weight is an inaccurate picture of nutritional status (eg a pregnant woman). Waist circumference

This measurement is a good indicator of intra-abdominal fat mass, and is a better predictor of risk for chronic diseases of lifestyle than is body mass index (BMI).

Interpreting the measurements Interpretation of the measurements is very important. If a measurement is simply taken but not interpreted, it will not show much about the nutritional status of the patient. Nurses who become familiar with interpreting the measurements, will find them to be a valuable tool in assessing and monitoring patients’ progress. It is also important to give feedback to patients or their caregivers, and to counsel them on the necessary corrective action(s). Interpreting weight and length/height in children

Growth charts are most commonly used to interpret the growth of children. The new Road to Health booklet contains three different growth charts from the World Health Organization (WHO), namely weight-for-age, height-for-age and weight-for-height. These growth charts can be viewed on the WHO website at www.who.org. Each of these growth charts assesses different aspects of growth in the child and has z-scores which help classify the child’s growth (see Table 20.5). It is important to remember with children’s growth that it is monitored over time – as shown in the shape of the child’s growth curve – and that any special circumstances (such a low birth weight) must be considered when interpreting a child’s growth pattern. The nurse should always give the mother feedback about the growth of her child. Praise her if her child is growing well, and offer advice or intervention if the child is not growing according to the expected rate. Table 20.5  How to classify a child’s growth according to the different growth charts Growth indicators z-score

Above +3

Length/height for age

Weight for age

Weight for length/height

Child very tall; rarely seen Endocrine disorder

May be growth problems; assess weight for length/ height

Obese ➙

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Above +2

–

–

Overweight

Above +1

–

–

Possible risk of overweight

0 (median)

–

–

–

Below −1

–

–

–

Below −2

Stunted

Underweight

Wasted

Below −3

Severely stunted

Severely underweight

Severely wasted

Source: Western Cape DoH (2011)

Interpreting weight and height in adults using the BMI

For people older than 18 years, the BMI indicates whether their weight is appropriate for their height and may provide a useful estimate of malnutrition. Keep in mind, however, that because the BMI cannot show a person’s body composition (ie how much muscle, fat or fluid makes up the body) the results should be used with caution in people who have fluid retention or are very muscular (eg athletes). To calculate BMI, take the person’s weight (in kg), divide it by their height (in m) and by their height (in m) again.

Working out BMI BMI = weight (in kg) ÷ height (in m) ÷ height (in m) For example: A person weighs 70 kg and has a height of 168 cm. What is his BMI? BMI = 70 ÷ 1.68 ÷ 1.68 = 24.8

Then use Table 20.6 to classify the patient’s weight according to his or her BMI: Table 20.6  Classification of weight according to BMI BMI

Interpretation

< 16

Severely underweight

16–16.9

Moderately underweight

17–18.4

Mildly underweight

18.5–24.9

Healthy weight

25–29.9

Overweight

30–34.9

Mildly obese

35–39.9

Moderately obese

> 40

Severely obese

Source: Charlton, Ferreira & Naude (2008), citing the WHO (1997)

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It is clear that the person in the example has a healthy weight for his height. It is important to understand that both a low BMI (being underweight) and a high BMI (being overweight) are associated with increased risk of disease. Interpreting weight in adults according to percentage of body weight lost

Percentage of body weight lost is normally used to assess the severity of malnutrition in persons with HIV, AIDS or TB. However, achieving a certain percentage weight loss in overweight patients who have non-communicable diseases can help in the management of their condition. Percentage weight lost can be calculated from a previous weight that was measured and recorded or from the person’s memory (although memory is, of course, not as reliable as a measured weight). To calculate the percentage weight lost, take the original weight and subtract the current weight to determine the difference. Then divide the difference by the original weight and multiply by 100.

Calculating percentage of weight lost Difference in weight = original weight (in kg) – current weight (in kg) Percentage weight lost = difference in weight (in kg) ÷ original weight (in kg) × 100 For example: A patient weighed 84 kg in March and now weighs 72 kg in September. What is his percentage weight loss? Difference in weight = 84 kg – 72 kg = 12 kg Percentage weight lost = 12 kg ÷ 84 kg × 100 = 14.3% over 6 months

Unintentional weight loss of 5% in one month or 10% in six months is considered to be a serious problem, especially in people who are living with HIV, AIDS or TB.

Biochemical or laboratory analysis Biochemical tests (analysis of blood, urine and other body tissues) are the most objective and sensitive indicators of nutritional status. These tests range from the quick fingerprick to determine a diabetic patient’s blood glucose to the blood that needs to be sent to a laboratory to determine the viral load of a patient with HIV infection. Results can provide valuable information regarding the patient’s health and nutritional status, but should be interpreted carefully as they can be influenced by disease and treatment. Clinical examination Clinical examination is an important part of the nutritional assessment because certain nutrient imbalances may be detected that cannot be identified with the other assessment methods. A thorough clinical assessment involves a systematic head-to-toe examination of the patient, looking at both his or her general condition and specific parts of the body. Signs to look out for include muscle wasting, hydration status (eg dehydration or oedema), pallor and poor wound healing. Give special attention to the areas where nutritional deficiencies often appear, for example the skin, hair, nails, eyes, lips, gums, teeth and tongue. Many of such signs will indicate a lack of several nutrients but the

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nurse should also be aware that some signs are not necessarily related to nutrition, and could be due to old age or other factors.

Diet history The goal of taking a diet history is to determine the nutrient content of the food consumed and to evaluate how appropriate it is for the particular patient. It can provide valuable information about the patient’s eating habits, appetite, lifestyle, preferences and dislikes, portion sizes, eating problems, use of complementary or alternative therapies, food availability, etc. Think about this… An important aspect to discuss is how the patient’s religion, culture or beliefs may influence the types of food they choose to include in or exclude from their diet. Common practices you may encounter include the following: • Islamic people eat halaal meat (that has been slaughtered according to specific religious laws). They avoid pork and alcohol, and fast from food and drink on certain holy days, especially during the month of Ramadan. • Jewish people eat kosher food (including meat that has been slaughtered and prepared according to specific religious laws). They also avoid pork and sometimes alcohol, and fast from food and drink on certain holy days. • Rastafarian people mostly follow strict vegetarian or vegan diets. • Vegetarian people eat mostly food from plant sources (eg vegetables, fruit, starches/ grains, nuts/seeds and legumes) while avoiding some or all foods from animal sources. Vegans eat only food from plant sources but lacto-vegetarians include milk products in their diet and lacto-ovo vegetarians include both milk products and eggs.

Preparing a nutritional care plan A nutritional care plan is aimed at achieving and maintaining optimal nutritional status within the context of the patient’s condition and environment, while contributing to alleviation of pain, discomfort and other effects of the disease. Once a comprehensive picture of the patient’s nutritional status has been assembled, a nutritional care plan can be prepared for the patient. The objective of such a plan may be relatively simple and easy to achieve, such as re-establishing fluid balance after dehydration (by providing fluid either by mouth, via a feeding tube or intravenously) or it could be complex, needing long-term intervention, such as rehabilitating a severely malnourished child (that will require interventions by different members of the healthcare team over several months). Determining nutritional goals or outcomes is a mutual effort between the nurse, the patient (or caregiver) and other members of the healthcare team. These outcomes should include achieving and maintaining optimal nutritional status, achieving a healthy body weight, preventing complications associated with malnutrition, and promoting optimal nutritional practices and a healthy lifestyle. To provide for continuity of care, the nurse should consider the patient’s need for assistance with nutrition after discharge from the hospital. Some patients may need to see a dietitian for nutrition education or support, whereas others may need to be referred 404

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to the Nutrition Therapeutic Programme at their primary healthcare facility. Some patients may need social services to assist them with food parcels or grant applications, and others may need community-based carers to provide home care. Remember to refer patients to the relevant people so that they can receive continued care and achieve an optimal nutritional status even when they are no longer in your care.

Implementing a nutritional care plan Implementation of a nutritional care plan in the clinical area involves three major interventions, namely collaborating, educating and monitoring. In the hospital setting, the nurse may collaborate with the doctor, the dietician and the food service manager regarding the nursing interventions needed to promote optimal nutrition for patients. This could include ordering a special diet from the kitchen, giving nutrition supplements, etc. In the community setting, the nurse’s role will be largely educational. Nutrition counselling involves more than just providing information, and the nurse should assist patients to integrate diet changes into their lifestyle and provide strategies to motivate them to change their eating habits in a way that is sustainable. Monitoring will determine whether there is improvement or deterioration in nutritional status and will allow modifications to be made in the care plan.

Diets used in hospital/care facilities Diets can be modified in different ways by altering either the nutrients or the consistency of the meals. Providing a special diet will help provide for patients’ specific needs and help them achieve/maintain a good nutritional status. The variety of special diets that are available will differ between facilities depending on various factors such as the level of healthcare provided, the training of staff and the available facilities in the food service unit. Special diets will mostly be requested/ prescribed by the dietitian or doctor but it would be valuable for the nurse to know the characteristics and indications of each one. Table 20.7  Diets used in hospital/care facilities Diet

Characteristics

Indications

Full

• Contains a variety of foods prepared using any cooking method

• No special dietary needs

Light

• Foods that are easy to digest • Mechanical: avoid pips, seeds, whole grains, fried foods, and anything hard, dry or tough • Chemical: avoid spices, acidic foods (eg vinegar, lemon) and gas-forming foods (eg cabbage, cucumber, beans) • Temperature: avoid food that is too hot or cold

• Transition from fluid to full diet • Following surgery

Soft

• Foods that are easy to chew or can be pressed against the palate with the tongue • Sauces are often added to make foods easier to swallow

• Chewing or swallowing difficulties* • Painful mouth 

➙

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Diet

Characteristics

Indications

Puree

• Foods from the light and/or soft diet are mashed or pureed in a food processor

• Chewing or swallowing difficulties* • Painful mouth

Clear fluid

• Limited to clear fluids, for example water, clear juices (apple, grape, berry), clear soups, tea (without milk) and jelly • Aim is to relieve thirst, prevent dehydration and minimise stimulation of the gastrointestinal tract

• Preparation for gastrointestinal surgery • Following gastrointestinal surgery • Severe nausea, vomiting or diarrhoea

Full fluid

• Contains only liquids or foods that become liquid at room temperature • It is low in fibre, protein and iron, and can be high in saturated fat (especially when a lot of milk products are given) • It is not nutritionally adequate for long-term use unless patients are receiving supplemental drinks

• Transition from clear fluid to full diet • Chewing or swallowing difficulties* • Painful mouth

Diabetic

• Contains no sugar or sweet foods, and is high in fibre and low in fat • Portion sizes are measured • Meals are distributed through the day to ensure better blood glucose control, for example by providing snacks between meals

• Diabetes mellitus • Sometimes also indicated for obesity or cardiovascular disease

High protein

• A full diet supplemented with extra protein and energy in the form of nutritious foods (eg an extra egg with breakfast) and/or supplemental drinks

• Malnourished patients • Increased energy requirements (eg HIV, TB or cancer)

Low protein

• Protein sources (meat, chicken, fish, eggs and milk products) are restricted by providing smaller portions that are measured/strictly controlled • Sodium, potassium, phosphate and fluid may also be restricted in this diet

• Renal impairment

Low salt

• Contains no added salt and limits foods containing sodium (eg processed foods, processed meats, tinned products, stock and soup powders)

• Hypertension • Congestive heart failure • Renal impairment • Liver disease with ascites

*Remember to consult with the speech therapist to determine which textures will be most appropriate for the patient who has swallowing difficulties.

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Ensuring adequate food intake The appetite of patients may be decreased by several factors such as illness, physical discomfort or pain, unfamiliar food, and environmental and psychological factors. Some patients may need to be assisted during meals, while others may need to be fed. Before feeding patients, position them in a way that is comfortable and safe for feeding (an upright position decreases the risk of aspiration). Ask them in which order they would like to eat the food and if they cannot see, tell them which food is being given. Always allow time for chewing and swallowing before offering more food. Although feeding a patient is time consuming, the nurse should try to appear unhurried and convey that there is ample time. Sitting at the bedside, if possible, is one way of conveying this impression. It is important to make the time pleasant by conversing with the patient throughout the meal. Normal utensils should be used whenever possible. Patients who have difficulty drinking from a cup or glass may be offered a straw or a special cup with a spout (feeding cup), as this will enable them to drink liquids with less effort and less spillage. Patients who have difficulty handling normal utensils can be given assistive devices to help them maintain their independence. This includes utensils with bent or angled handles to compensate for limited motion, or bands attached to the end of the handle and fitted over the patient’s hand to prevent the utensils from being dropped. In these cases, an occupational therapist can assess the need and provide the best recommendations and/ or devices. Think about this… Aspects to keep in mind when providing meals to patients • Provide a clean environment that is free of unpleasant sights and odours (remove urinals/bedpans and close the doors leading to the toilet). • Allow/assist patients to wash their hands before meals. • Encourage/provide oral hygiene before meals – this improves the patient’s ability to taste. • Avoid unpleasant/uncomfortable treatments before/after meals. • Provide familiar, culturally appropriate food that the patient prefers. • Relieve illness symptoms that decrease appetite before meals, such as giving an analgesic for pain or an antipyretic for fever. • Assist the patient to sit in a chair or a comfortable position in bed, whichever is permitted and appropriate. • Clear the overbed table to make space for the tray and make sure it is clean and hygienic. • Arrange the overbed table close to the bedside so that the patient can reach and see the food. • Always check to ensure that the patient has the correct special diet. • Assist the patient if needed in spreading bread, cutting meat, etc. • If the patient is blind, identify the placement of the food. • On completion of the meal, observe how much and what was eaten and the amount of fluid taken, and record this on the appropriate documents. • After each meal offer patients a mouth rinse or attend to their oral hygiene in order to ➙ prevent dental caries and halitosis.

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• Always check for any problems during or after meals, for example if the patient does not eat, or experiences nausea and/or vomiting, chewing and/or swallowing difficulties, or pain. Report these observations to the relevant person and record them on the appropriate documents.

Enteral nutrition When the patient is unable to ingest sufficient foods orally or the upper gastrointestinal tract is impaired and the transport of food to the small intestine is interrupted, enteral nutrition should be provided. Nutrients are administered into the gastrointestinal tract through a tube, directly into the stomach (nasogastric) or the small bowel (nasoenteric). Patients who require long-term enteral feeds may receive a percutaneous endoscopic gastroscopy (PEG) where a tube is surgically placed directly into the stomach through the abdominal wall. The decision on where to place the tube depends on various factors such as how long the patient will need enteral feeds, the risk of aspiration or displacement, the patient’s digestive or absorption capacity, and the volume of feed that needs to be administered. The selection of an appropriate enteral formula depends on the patient’s diagnosis and nutritional needs as well as factors such as budget, convenience and available facilities. Standard (or polymeric) feeds are nutritionally balanced with an acceptable taste and a reasonable price, but require that the patient has normal digestive and absorptive function. A patient with compromised gastrointestinal function will most likely receive a semi-elemental (or partially digested) feed which is less palatable and more expensive, but allows the patient to absorb nutrients more easily. Some patients may also require disease-specific feeds that are specially designed for certain conditions, such as diabetes or renal impairment. The frequency of feeds and amounts to be administered will be calculated by a dietitian or doctor according to the patient’s nutritional requirements. Feeds are often started at a quarter to half the goal volume, and increased gradually according to the patient’s tolerance. Enteral feeds can be administered as bolus feeds, intermittent drip or continuous drip. With bolus or intermittent drip feeds, the total daily amount of enteral formula is divided into portions and administered several times per day by a syringe, gravity drip or infusion pump. These feedings should be given only into the stomach and the patient must be monitored closely for distension and aspiration. Continuous feedings are usually administered over 24 hours using an infusion pump that ensures a constant flow rate. These are used for patients who do not tolerate large volumes of feed at once, and are essential when feedings are administered into the small bowel. The total daily amount of enteral formula is divided by the number of hours that the feed will be administered. Cyclic feedings refer to continuous feedings that are administered in less than 24 hours. These feedings, often administered at night, allow the patient to attempt regular eating through the day. The most common complications in patients receiving enteral feeds are aspiration of formula and diarrhoea. The risk of aspiration can be reduced by giving feeds slowly and raising the patient’s head and shoulders above the chest during and after feeding. Diarrhoea can be prevented by giving feeds slowly, ensuring correct concentration and preparing feeds hygienically. Remember that diarrhoea can also be caused by various 408

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other factors such as bacterial overgrowth, medications or illness, and the actual cause should be identified and addressed before adjusting or withholding feeds.

Parenteral nutrition Parenteral nutrition is provided when the gastrointestinal tract is non-functional because of an interruption in its continuity or because its absorptive capacity is diminished. Feeds are then administered intravenously in order to bypass the digestive tract. Parenteral nutrition would be indicated in patients with severe malnutrition (with a non-functioning gastrointestinal tract), severe burns, bowel disease disorders, moderate to severe acute pancreatitis, those who have undergone major surgery, or any condition where the gastrointestinal tract would be inaccessible for three to five days. Total parenteral nutrition (TPN) aims to provide all the patient’s nutritional requirements in a volume that is well tolerated. A central venous catheter is inserted into the superior vena cava, which allows concentrated feeds to be administered to the patient long term. Peripheral parenteral nutrition (PPN) refers to feeding through a catheter that is inserted into a small vein (usually in the arm). It is a short-term method to provide patients with supplemental or transitional intravenous feeds during transition from parenteral to enteral feeds. Parenteral solutions consist of dextrose, water, fat, proteins, electrolytes, vitamins and trace elements. Feeds can be customised according to a patient’s specific needs by mixing single units of nutrients together, but all-in-one or multi-chamber bags (containing all the necessary elements) are more commonly used. Parenteral solutions are high in glucose so infusions are started gradually over two to three days to prevent hyperglycaemia. Feeds can then be administered by continuous infusion (over 24 hours) or cyclic infusion (over 8–12 hours, usually at night) to improve quality of life. When parenteral feeds are discontinued, this should also be done gradually to prevent hypoglycaemia. Monitoring patients for potential complications is of great importance. Complication can be mechanical, such as an air embolism, or metabolic, such as electrolyte abnormalities, but the greatest risk remains the potential for infection. Be sure to monitor patients closely for any signs of infection and always observe surgical aseptic technique when changing solutions, tubing, dressings and filters. Special community nutritional services There are various community-based programmes that can assist in the nutrition support of people who are at risk of malnutrition. The Nutrition Therapeutic Programme (NTP) is an initiative by the Department of Health, and operates in South African primary healthcare facilities. The main target groups are children, pregnant and lactating women, and people living with HIV, AIDS and/or TB who are malnourished. There are specific criteria for each group, and patients on the programme receive enriched porridge, energy drinks and/or ready-touse therapeutic food for six months. Food parcels are provided to some people who are at risk by the Department of Social Development or local NGOs. The National School Nutrition Programme of the Department of Education provides meals to children attending schools in communities affected by poverty. The main

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aim is to improve the education of learners by relieving hunger and the effects of malnutrition on learning abilities. Many communities also have charity or faith-based organisations that provide cooked meals to vulnerable people such as the homeless, the elderly and people living with HIV, AIDS and/or TB. As these people are often identified and referred by a healthcare facility, it is important for nurses to know which organisations are actively at work in their community so that they can work with them.

Evaluation of nutritional outcomes Ongoing evaluation from the onset is vital in order to provide a patient with costeffective treatment and results. In a hospital/care facility, nurses may need to monitor how well patients tolerate their meals. The reason for meals not being eaten needs to be investigated as this may affect a patient’s nutritional status and progress. Meals that are not tolerated may need to be adapted to assist the patient in recovery. At primary healthcare level, evaluation may include growth monitoring and promotion of a malnourished child on the Nutrition Therapeutic Programme, or monitoring the weight of a person with diabetes. In each case, the goals that were established during the planning phase should be evaluated according to specific desired outcomes so that interventions can be continued, adapted or stopped if the goals have been achieved.

Common nutrition-related problems The prevention of disease and the promotion of health is one of the important functions of a nurse, thus it is important to develop the ability to identify disorders and give appropriate health education aimed at preventing complications. There are various problems that can affect a person’s ability to maintain an optimal nutritional status. This can be caused by an inability to take in sufficient nutrients (eg poor appetite, sore mouth, increased nutritional needs) or it can be due to the loss of valuable nutrients (eg through vomiting or diarrhoea). Being informed about the interventions and medical management of these problems is only a part of the care process. There is much advice that the nurse can offer patients in addition to (or sometimes instead of) conventional therapy that should help to relieve some of the symptoms and help them to attain a good nutritional status. (See Table 20.8 for common nutrition-related problems.) The nurse’s management objectives would include the following: • Identify the cause. • Address the issue. • Relieve symptoms. • Prevent further complications. • Provide medical therapy. • Health promotion/education. • Refer.

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Causes

• Poor oral hygiene • Vitamin B deficiency • Poorly fitting dentures • Immuno-suppression leading to opportunistic infection • Long-term use of broad spectrum antibiotics/corticosteroids • Stroke (causing dysphagia) • Poor hygiene of feeding bottles • Dental/facial surgery

• Illness • Medication • Depression • Anxiety • Micronutrient deficiency

Problem

Sore mouth/ swallowing problem

Poor appetite

Table 20.8  Common nutrition-related problems

• Pain relief • Oral care • Appropriate medication –– Antibiotics –– Antiviral agents (local/systemic) –– Antifungal agents • Test for HIV if status is unknown • Ensure proper-fitting dentures • Correct nutrition deficiencies • Refer to speech therapy to assist with swallowing difficulties

Interventions

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• Take small, frequent meals (5–6 meals per day) • Ensure that meals are nutritious • Eat in a relaxing environment with friends or family, and make mealtimes ➙ enjoyable

• Good oral hygiene (regular brushing and rinsing) • Salt-water mouthwash • Ensure adequate hydration • Give fluids with meals so that sips of fluid can be taken after food to make swallowing easier • Adjust the consistency or texture of the food to make it easier to chew and/ or swallow • Encourage soft, bland foods • Avoid hard/crunchy/spicy/acidic foods for sore mouth • Avoid sticky/dry foods for swallowing difficulties • Cold foods and drinks or ice may relieve discomfort and pain • Use a straw for liquids or soups • Encourage mothers to cup feed instead of using bottles and educate on good hygiene

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Causes

• Disease: –– TB infection –– HIV infection –– Diabetes –– Cancer –– Thyroid dysfunction • Inadequate food intake: –– Poor appetite –– Sore mouth/swallowing problem –– Nausea/vomiting –– Stress –– Poor food security • Worm infestation

Problem

Weight loss

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• Screen for possible disease • Deworm • Investigate social circumstances • Refer to social worker • Refer for Nutrition Therapeutic Programme (NTP)

Interventions

➙

• Counsel according to the cause (ie if due to poor appetite, see appropriate section) • If due to social circumstances, counsel on economical meals

• Take care with the presentation of meals so that they are attractive and appetising • Try to stimulate appetite by eating favourite foods • Avoid drinking fluids before or during meals as this can fill the stomach; rather drink fluids between meals • Enrich foods by using products such as margarine, oil, peanut butter, milk, eggs and sugar to increase the energy and/or protein content of the meal. Stir margarine or peanut butter into porridge, sweeten vegetables or make scrambled eggs

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Causes

• Viral infection • Motion sickness/dizziness • Early pregnancy • Medication • Alcohol abuse

• Infection –– Poor hygiene –– Immunosuppression • Worm infestation • Lactose intolerance

Problem

Nausea and vomiting

Diarrhoea

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• Oral rehydration solution • Intravenous therapy if unable to keep fluids down • Appropriate medication –– Ciprofloxacin –– Loperamide

• Oral rehydration solution • Intravenous therapy if unable to keep fluids down • Refer if: –– dehydrated –– shocked –– known diabetic –– jaundiced –– showing signs of intestinal obstruction (no stools/flatus) –– presenting with abdominal pain/ tenderness with guarding and rigidity –– infants have projectile vomiting –– vomit contains blood –– vomit is dark green, brown or smells like faeces –– regular vomiting lasts more than 24 hours, especially if accompanied by abdominal pain

Interventions

• Drink plenty of fluids (water and oral rehydration solution) to prevent dehydration • Eat small, frequent meals • Eat foods containing soluble fibre (eg oats, legumes and apples without the ➙ skin)

• Eat small, frequent meals (5– 6 per day) and chew food slowly • Maintain adequate hydration with clear fluids • Drink fluids between meals instead of with meals • Eat lightly salted and dry foods (such as salty crackers or toast) • Avoid fatty or oily and spicy foods • Eat simple foods (such as rice, mashed potato, toast, noodles, scrambled eggs, banana or custard) • Remain upright for about 20 minutes after eating before lying down • Cold foods/drinks are usually better tolerated than hot foods/drinks. This also prevents the odour of the hot food worsening the nausea • Open windows to allow for good ventilation of the room/house • Maintain good oral hygiene • Apply a cool compress to the forehead to assist the patient to relax

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Constipation

Problem

• Education on non-drug approaches • Appropriate medication –– Senosides • Refer if: –– no stools or wind in past 24 hours with abdominal pain and vomiting

–– Co-rimoxazole –– Metronidazole • Test for HIV if status is unknown

• Osmotic diarrhoea (too much sugar, often from dried fruit)

• Diet/lifestyle • Medication –– Amitriptyline –– Codeine/morphine –– Antacids –– Iron supplements • Pregnancy

Interventions

Causes

• Drink more fluids, especially water • Eat more foods that contain fibre such as whole-wheat bread, oats, vegetables, fruits, dry beans, peas and lentils • Be more active and take part in exercise according to ability (aim for 20 min per day) • Avoid chronic laxative use or ➙ enemas

• Eat foods containing potassium (eg bananas and potatoes) to replace losses in the stools • Avoid fatty or oily foods • Avoid foods containing insoluble fibre (eg whole-wheat bread, bran, nuts and seeds) as these can irritate the gut • Avoid foods or drinks containing caffeine (eg coffee, Ceylon tea, cola and chocolates) as these can stimulate the gut and worsen symptoms • If milk and milk products worsen the symptoms, avoid them, although fermented milk products (eg yoghurt and maas) may still be tolerated • Ensure good personal hygiene, especially hand washing

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Causes

• Relaxed gastro-oesophageal sphincter pressure –– Spicy food –– Peppermint –– Alcohol –– Fatty foods –– Smoking –– NSAIDs

• Pelvic infection • Constipation • Abdominal mass • TB • Cancer • Worm infestation • Irritable bowel syndrome

Problem

Heartburn/ indigestion

Abdominal pain

• Pain relief • Appropriate medication: –– Paracetamol –– Magnesium tricilicate suspension • Deworm • Stop NSAIDS/aspirin • Refer if: –– peritonitis

Interventions

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• As above • Discuss normal bowel functions and frequency

➙

• Eat small, frequent meals • Eat slowly and chew food well • Avoid large meals containing lots of fat at least 3–4 hours before lying down • Avoid rigorous exercise soon after eating • Do not smoke (this relaxes the lower oesophageal sphincter between the stomach and oesophagus) • Avoid alcohol and foods or drinks containing caffeine (eg coffee, cola and chocolates) • Avoid the use of spearmint and peppermint • Avoid spicy, acidic or gas-forming foods and carbonated drinks • Wear loose-fitting clothing, and avoid tight belts or clothing that can increase pressure on the stomach

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Problem

Causes –– jaundiced –– fever –– no stools or wind in past 24 hours and vomiting –– no urine passed for last 12 hours and swelling of abdomen –– pregnant with BP > 140/90 –– associated with chest pain –– recurrent with constipation and/or diarrhoea and bloating –– loss of weight/appetite –– blood in stools –– persistent vomiting/vomiting blood

Interventions

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Chapter 20  Nutrition

Conclusion Through this chapter nurses should have a greater awareness of the major nutritionrelated challenges that South Africa is facing as malnutrition affects the population in the form of under-nutrition, over-nutrition and various micronutrient deficiencies. The characteristics of nutrients, the importance of nutrition through each phase of the life cycle and the value of nutrition in the prevention and/or management of health conditions have been described. This will equip nurses in assessing the nutritional status of patients, as well as preparing, implementing and evaluating nutritional care plans for them. In studying this chapter, nurses will also be empowered to offer appropriate advice regarding various conditions. By using this knowledge they can play a key part in helping to achieve optimal nutrition for all people in their care.

Suggested activities for students Activity 20.1 Discuss the benefits of exclusive breastfeeding for the mother and the child.

Activity 20.2 Calculate your own body mass index (BMI) and classify your weight accordingly.

Activity 20.3 Adapt the following menu for an elderly person who does not have teeth or dentures. Breakfast Oats porridge with milk and sugar Apple Lunch Chicken pieces Samp Green beans Beetroot salad Supper Fried egg Whole-wheat bread Sliced tomato ➙

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Activity 20.4 You are working as a nurse at a primary healthcare facility. Mr September, one of your patients who has TB, weighs 47 kg today. His usual weight is 55 kg. He recently lost his job as he is too weak to work and complains of a decreased appetite. • Calculate Mr September’s percentage weight loss. Are you concerned? • List all the possible reasons for his decreased appetite. What advice would you offer him? • Compile a brief nutritional care plan including your goals and possible interventions to help Mr September achieve an optimal nutritional status.

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chapter

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Assessing and maintaining fluid, electrolyte and acid– base balance

Learning objectives On completion of this chapter, the student should be able to do the following: • Describe the maintenance of fluid, electrolytes and acid–base balance in the body. • Identify the factors that affect fluid intake and output. • Assess fluid, electrolyte and acid–base status comprehensively. • Interpret the assessment findings correctly. • Give prescribed oral and intravenous fluids correctly. • Provide care for patients on fluid and electrolyte therapy. • Describe the measures used to prevent complications related to fluid imbalance. • Measure and record intake and output accurately. • Give essential health education to patients with fluid, electrolytes and acid–base imbalances.

Key concepts and terminology Acid: A substance that is capable of donating or giving up hydrogen ions to other molecules. Acidosis: Acid–base imbalance characterised by an increase in hydrogen ions concentration/decreased blood pH. Active transport: Physiologic pump that moves molecules across a cell membrane from an area of lower to one of higher concentration. In active transport, molecules move against the concentration gradient and therefore require an input of energy/push from the cell (adenosine triphosphate or ATP). Alkalosis: Acid–base imbalance characterised by a decrease in hydrogen ions concentration/increased blood pH. Base: A substance that is capable of accepting hydrogen ions from other molecules, thereby becoming alkaline. Dehydration: A condition whereby the body cells lose water if not adequately replaced. Diffusion: Movement of solutes from an area of high concentration, across a semipermeable membrane to an area of low concentration until the concentrations in both areas are equal. ➙

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Electrolytes: Substances that, when in solution, dissociate into electrically charged particles called ions which may have positive or negative charges. Fluid volume deficit: Fluid imbalance caused by the active loss of excessive amounts of body fluid. Fluid volume overload: Extracellular fluid volume excess. Homeostasis: State of stability, balance or equilibrium in a biologic system. Osmosis: Movement of a fluid through a semi-permeable membrane from an area of low concentration of solutes to an area of high concentration until the concentrations in both areas are the same. pH: A measurement used to express acidity or alkalinity of a solution. Low pH numbers indicate an acid state and high pH numbers an alkaline state.

Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy and physiology • Chemistry and biophysics.

Medico-legal considerations The scope of practice of registered nurses authorises them to implement the following in relation to the maintenance of fluid, electrolyte and acid–base balance: • The supervision and maintenance of fluid, electrolyte and acid–base balance in a patient • The facilitation of the maintenance of bodily regulatory mechanisms in a patient.

Ethical considerations In relation to the maintenance of fluid, electrolyte and acid–base balance, failure to carry out the assessment, diagnosis, treatment, care, prescription, collaboration, referral, co-ordination and patient advocacy as the scope of practice permits is deemed to be acts and omissions in respect of which the South African Nursing Council can take disciplinary steps against the nurse.

Essential health literacy Water-borne diseases such as salmonella and cholera are endemic in South Africa and every year many avoidable deaths occur due to gastrointestinal disease. The importance of a clean water supply cannot be over emphasised. Ensuring a clean water supply to every community is a government priority, even though it is likely to take many years before every community is reached.  ➙

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Until that time, communities need to know how to make water safe for human consumption. Education should concentrate on the prevention of water pollution and also on how to economically sterilise water used for drinking. Water can be sterilised by boiling it, or by adding 5 ml of hypochlorite to 20–25 litres of water and allowing to stand for 30 minutes. Dehydration during exercise or during physical labour is common during the hot months, and it is essential that the community realises the importance of drinking enough water during physical exertion.

Introduction The fluids of the body are a complex solution of water, salts, proteins, nutrients and waste products, as well as other organic molecules, such as fats, lipoproteins, hormones, enzymes and cholesterol. All of the body’s chemical and metabolic processes take place within this fluid environment, and it is therefore essential that this environment remains constant, and that fluctuations in the composition of body fluids are kept within a specific normal range. The process of homeostasis normally maintains this state of balance. However, in illness these homeostatic mechanisms are often disrupted, with the result that those who are frequently ill present with imbalances of fluid, electrolyte and acid–base. Fluid and/or electrolyte and acid–base imbalances are potentially life threatening, and it is essential for the nurse to be constantly on the alert for their development. The purpose of this chapter is to provide the basic knowledge required to achieve positive outcomes for the nursing care of patients at risk of and/or with common clinical problems related to fluid, electrolyte and acid–base imbalances.

Maintenance of fluid balance Human bodies are made up of 45–75% fluids. The body of an infant contains 75% fluid, whereas that of an elderly person consists of at least 45% fluid. The percentage of body fluid varies with age, gender and the amount of body fat. The greater the amount of adipose tissue, the less water is present, because adipose tissue does not contain water. Body fluid is distributed as shown in Table 21.1 Table 21.1  Distribution of body fluid Intracellular fluid

Extracellular fluid

Fluid found within body cells – this is 60% of the total (±25 litres) body fluid

Fluid found outside body cells – this is 40% of the total (±15 litres) body fluid. The fluid is inclusive of: • interstitial fluid, which is found in between the cells • intravascular fluid, which is found within the blood vessels (ie blood and plasma) • transcellular fluid, which is neither interstitial nor intravascular (ie glandular secretions)

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Fluid balance can only be maintained if fluid intake equals fluid output. During a 24-hour period, an individual takes in approximately 2 500 ml of water through eating and drinking, as well as the water produced as a by-product of metabolic processes in the body, whereas an estimated 2 600 ml fluid is lost via urine, faeces, sweat and exhaled air. Table 21.2  Fluid gain and fluid loss in 24 hours Fluid gain/in

Fluid loss/out

Food: approx. ±1 000 ml Fluids: approx. ±1 200 ml Metabolic water: ±300 ml

Sweat: ±650 ml, depending on the weather Exhaled air: ±350 ml Faeces: ±200 ml Urine: ±1 300 ml

Insensible loss Fluid lost via the skin and lungs is known as insensible loss. The amount of this insensible loss depends on the temperature of the environment. It is normally between 600 and 1 000 ml. In the case of a patient who is at rest and whose physical activity is minimal, the insensible loss can be assumed to be between 400 and 600 ml. Obligatory loss This is the minimum amount of urine that must be passed in order to excrete metabolic wastes: approximately 500 ml per day. Fluid is also lost via the intestines. The amount of fluid lost via the bowel tends to remain constant. If the individual is dehydrated, however, the faeces become hard and dry as maximum amounts of fluid will be reabsorbed from the large intestine.

When fluid losses exceed fluid intake, the individual becomes thirsty and takes in more fluid in order to correct the fluid deficit. Centres in the brain initiate the thirst mechanism. A dry mouth also stimulates thirst. A fluid deficit causes the normally moist mucous membranes of the mouth to become dry and this makes the individual feel thirsty. Output is regulated primarily by the kidneys, which are able to adjust the volume of fluid lost as urine according to the amount of fluid present in the body. As a general rule, if output exceeds intake, the kidneys retain fluid and the urine output decreases. If intake exceeds bodily requirements, the kidneys retain less fluid and the urine output increases.

Electrolyte balance Electrolytes are minerals and salts that are found in the body fluids, which are essential for health. They play an important role in maintaining the constancy of the internal environment of the body. Electrolytes are electrically charged, either positively or negatively. Positively charged electrolytes are known as cations, while negatively charged electrolytes are known as anions. Electrolyte concentrations in the body are expressed in millimoles per litre (mmol/L), which indicates the number of particles present.

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Table 21.3  Electrolyte concentrations in body fluids Electrolyte Sodium Potassium Calcium Magnesium Chloride Bicarbonate Phosphate Proteins Organic acids

Plasma 146.0 4.0 2.5 1.5 105.0 25.0 2.0 4.0 16.0

mmol mmol mmol mmol mmol mmol mmol mmol mmol

Interstitial 142.0 mmol 4.0 mmol 2.4 mmol 1.4 mmol 108.0 mmol 28.0 mmol 2.0 mmol (proteins + organic acids = 10.0 mmol)

Intracellular 14.0 140.0 0.0 31.0 5.0 11.0 70.0 99.0

mmol mmol mmol mmol mmol mmol mmol mmol

NB! Figures given represent an average figure, and not the normal range.

Table 21.4  Major electrolytes in the body and their function Electrolyte

Functions

Sodium [Na+]

• Sodium is the chief cation of the extracellular fluid which regulates the movement of water within the body • Important for the maintenance of acid–base balance • Required for many of the chemical reactions, which take place within the cell • Essential for nerve activity and conduction of electrical impulses within the body

Potassium [K+]

• Chief cation of the intracellular fluid, essential for chemical activity within the cell • Essential for normal excitability and stimulation of nerve and muscle tissue, particularly in the myocardium

Chloride [Cl–]

• Chief anion of the extracellular fluid, essential for the maintenance of acid–base balance • Essential for the formation of hydrochloric acid

Calcium [Ca++]

• Essential for building bones and teeth • Regulates the excitability of nerve and muscle tissue • Required for the normal coagulation of the blood

Magnesium [Mg++]

• Essential catalyst in the body • Essential for the normal function of heart, nerves and muscle tissue

Phosphate [PO4–]

• Chief anion of the intracellular fluid • Forms part of the substance of bone • Required for the transfer of energy within the cell • Required for the transfer of energy during cell division and the replication of DNA • Required for normal nerve and muscle function • Essential for the maintenance of acid–base balance

Bicarbonate [HCO3]

• Essential for the maintenance of acid–base balance • Forms part of the bicarbonate buffer system

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The intake of electrolytes in the form of the various minerals contained in food is mandatory. A balanced diet, which contains adequate amounts of all essential nutrients, will provide all of the body’s electrolyte requirements, as well as the vitamins needed to absorb the minerals.

Clinical alert! NB! It is important for a nurse to monitor the patient’s dietary intake in order to ensure that a balanced diet is taken. It is all very well to order a balanced diet, containing adequate amounts of all essential nutrients, but this will be wasted unless the patient actually ingests the food. Patients whose nutritional intake is inadequate are prone to develop electrolyte imbalances. Regulation of electrolyte balance

The regulation of electrolyte balance is mainly carried out by the kidneys, which excrete excess electrolytes and conserve those needed by the body. The ability of the kidneys to perform this function does, however, depend on the volume of body fluid. Too little body fluid means that insufficient urine is formed by the kidneys to excrete waste products and excess electrolytes. A body fluid overload will result in increased urine formation, and needed electrolytes may be lost through being ‘washed out’ with the large volume of urine.

Acid–base balance The quality of the internal environment of the body depends not only on fluid and electrolyte concentrations but also on the acidity/alkalinity of the body fluids. The body’s regulatory mechanisms must maintain a delicate balance between the concentrations of acids and those alkalis or bases. The correct ratio between acids and bases is essential for the normal chemical and physiological processes of the body. The ratio of acids to bases in the body is reflected by the pH, which is an indication of hydrogen ion concentration in the body fluids. A decreased pH indicates that this ratio has increased – that is, there are more acids present – thus increasing the number of acids relative to the number of bases; the body fluids thus become acidic. An increased pH means that the ratio of acids to bases has decreased – that is, there are fewer acids present relative to the number of bases – and the body fluids thus become more alkaline. The pH of the body fluids is slightly above neutral at 7.40, and ranges between 7.35 and 7.45, depending on conditions in the body. This 7.35–7.45 range is the norm for plasma, as well as for extracellular and intracellular fluid. Other body fluids, however, have specific pH ranges depending on the chemical functions that take place in that fluid. Table 21.5  pH of body fluids Fluid Saliva Gastric juice Duodenal juice

pH range

5.5–7.5 1.5–1.8 5.5–7.5 ➙

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Fluid Bile Pancreatic juice Urine Blood

pH range

5.5–7.7 7.5–8.2 4.5–8.0 7.35–7.45

The regulation of acid–base balance is carried out by the lungs and kidneys, which excrete excess acids and maintain the pH within the normal range.

Nursing assessment of fluid, electrolyte and acid–base balance In order to assess disturbances of fluid, electrolyte and acid–base balance, nurses need to enquire about the following: • Has the patient sustained any abnormal loss of body fluid? • Does the patient have any dietary restrictions, whether religious, self-imposed or as treatment for a medical condition? • Is the patient taking in adequate amounts of food and fluids? • Is the patient’s diet balanced, and does it contain adequate amounts of all the necessary nutrients? • How does the patient’s fluid intake compare with fluid output?

The patient’s history In order to assess disturbances of fluid, electrolyte and acid–base balance, a nurse should focus on the following factors when taking a history from a patient: • Has there been any recent change in the patient’s pattern of intake and output, such as anorexia, vomiting, diarrhoea, constipation and an abnormal thirst? • How much food and fluid does the patient normally take in over a 24-hour period? • What medications, if any, is the patient taking? • Has the patient experienced any rapid weight gain or loss recently? Physical assessment 1. Temperature. The normal temperature-regulating mechanisms of the body are disturbed by fluid, electrolyte and acid–base imbalances: • An elevated temperature may occur in dehydration or in infection, leading to excess loss of fluids. • A subnormal temperature as well as cold extremities may also indicate fluid depletion, especially if the fluid loss is severe. 2. Pulse. The pulse is an indirect indicator of cardiac function. Cardiac function may be affected by fluid, electrolyte and acid–base disturbances: • An increased pulse rate occurs in fluid volume deficit, as a compensatory mechanism due to the drop in cardiac output. • A rapid, weak and thready pulse indicates impending circulatory collapse due to fluid volume deficit. • A full bounding pulse with extra systoles is frequently found in potassium imbalance. 425

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3. Respiration. Nurses should be aware of the following: • Deep sighing respiration, known as Kussmaul’s breathing, is characteristic of acidosis. • Dyspnoea is seen in fluid volume excess, due to the fact that excess fluid from the circulation has entered the alveoli, causing respiratory distress. 4. Blood pressure. Blood pressure is an indicator of circulating blood volume: • Changes in blood pressure are frequently seen in fluid imbalances. • Hypotension is seen in fluid volume deficit. • Hypertension may indicate fluid volume excess. 5. Skin and mucous membranes. Changes in the tone and elasticity of the skin are particularly significant in the assessment of fluid balance, because tone and elasticity are related to the amount of fluid present in the subcutaneous tissue. Skin turgor is a reliable indicator of the fluid status. • Pinch test: When a small fold of skin is picked up with the fingers, the skin should rapidly resume its normal position when released. If the fold of the skin does not return to its normal position, but remains pinched, fluid Figure 21.1  Pinch test volume deficit is present. • Pitting: Normally the skin will resume its position after pressure has been applied with the fingertips. If the skin retains the imprint of the nurse’s fingertips for longer than 30 seconds, oedema is present. Oedema is a state in which excess fluid is present in the tissues, and may thus indicate fluid volume excess.

Figure 21.2  Pitting on pressure • Loss of skin turgor may also give rise to sunken eyes and a shrunken, pinched appearance to the face. In infants younger than 18 months, significant loss of body fluids causes a sunken fontanelle as well. 6. Urine. The character and volume of urine are very sensitive indicators of fluid, electrolyte and acid–base status. The kidneys play a key role in the regulation of fluid, electrolytes and acid–base status. • The specific gravity (SG) of urine indicates the amount of dissolved substances that are present in it and thus how concentrated or dilute it is. Normally the SG of urine varies between 1 008 and 1 030, depending on the individual’s fluid

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intake. A low SG (1 010 or less) occurs in fluid volume excess. A high SG (1 010 or more) is found in fluid volume deficit and in glycosuria where sugar is being passed in the urine, increasing the particle load of the urine. • Urine pH is an indirect indicator of acid–base status. An acid pH means an increased number of hydrogen ions being passed in the urine, indicating that the body fluids have become more acidic. An acid pH is normal during sleep and after a meal. Persistently acid urine is, however, abnormal and could indicate acidosis. Alkaline urine may be normal, particularly if the individual is a vegetarian, but persistently alkaline urine, in the absence of any dietary reason, could indicate that the body fluids have become more alkaline. • Urine output varies from individual to individual, depending on factors such as age, diet, fluid intake, physical activity and the weather. Normally the output varies between 1 400 and 2 500 ml in a 24-hour period. Decreased urine output may indicate fluid volume deficit. An increased urine output is seen in fluid overload, provided that kidney function is adequate. 7. Other physical findings. Other factors a nurse should be aware of are the following: • Changes in mental state frequently accompany disturbances in fluid, electrolyte and acid–base balance. Restlessness and confusion are very common early signs in many of the clinical problems related to fluid, electrolyte and acid–base balance. The elderly are very prone to develop problems of fluid, electrolyte and acid–base balance, and a change in mental state, or confusion, is frequently the first and only symptom. Infants are another vulnerable group. A lethargic ‘floppy’ baby who does not respond to stimuli may be suffering from fluid volume deficit. • Increased thirst is highly characteristic of fluid volume deficit.

Diagnostic tests Important information regarding the fluid, electrolyte and acid–base balance of a patient can be obtained from a laboratory analysis of a blood specimen. The following laboratory tests are carried out to assess fluid, electrolyte and acid–base balance: • Serum osmolarity (venous blood) shows the number of particles present in the sample and is an indicator of fluid status. • Serum electrolytes (venous blood) show the concentrations of the major extracellular electrolytes. • Blood gases (arterial blood) show the concentration of oxygen and carbon dioxide, as well as pH, bicarbonate levels and base excess/deficit.

Management of common clinical problems related to fluid, electrolyte and acid–base balance The following are common clinical problems nurses should be aware of and know how to manage.

Fluid volume deficit Fluid volume deficit, or hypovolaemia, is due to the active loss of excessive amounts of body fluid. Significant loss of body fluid leads to circulatory impairment, shock and ultimately death if it is not treated. It may be present in hospitalised patients who: 427

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• • • • •

are confined to bed, and who may not be able to reach their water are confused and therefore unable to respond to thirst are unconscious, on tube feeding and not receiving enough fluids are unable to swallow, or have difficulty in swallowing (dysphagia) have impaired thirst mechanism secondary to head injury.

Common causes of fluid volume deficit include severe diarrhoea, vomiting and use of diuretics without proper monitoring. Diarrhoea and vomiting are major causes of excessive fluid loss. Infant gastroenteritis secondary to diarrhoea and vomiting is a serious problem in South Africa, which results in many infant deaths. Polyuria as a result of hyperglycaemia or diabetes can also cause dehydration unless fluid intake is increased to compensate for such. Fluid losses can also be secondary to excessive sweating, for example due to sports, particularly if participants do not replace lost fluids; fever; severe burns; blood loss following trauma or surgery; gastrointestinal suction; and medical conditions such as acute renal failure and Addison’s disease. Long-distance running, popular in South Africa, yields an annual tally of individuals who collapse as a result of dehydration. Individuals carrying out manual labour in hot weather conditions are also at risk of dehydration. Typical signs and symptoms of dehydration are the following: • Loss of body weight • Thirst • Oliguria (reduced urine output) • Hypotension • Weak, rapid pulse • Dry mucous membranes of the eyes and mouth • Cold hands and feet • Headaches and fatigue • Poor skin turgor and a positive pinch test • A sunken fontanelle in infants under the age of 18 months • Restlessness and confusion, possibly due to a reduction in circulation to the brain • In the case of severe fluid volume deficit, the clinical signs and symptoms of shock may be present – that is pronounced hypotension; rapid, weak and thready pulse; oliguria; cold and clammy skin; and altered level of consciousness. Management

The primary principles in the management of fluid volume deficit are those of fluid replacement and the prevention of further fluid loss. Ideally, the lost fluids should be replaced with the same type of fluid. • Blood loss should be replaced with whole blood or plasma. • Gastrointestinal losses should be replaced with fluids containing electrolytes. Dextrose is usually given as well to maintain nutritional and energy requirements. Gastrointestinal fluid losses may be replaced orally or intravenously. The only contraindication for oral replacement is the inability to retain and absorb fluid or electrolytes from the gastrointestinal tract, as would be the case in vomiting and diarrhoea. In severe gastroenteritis, active replacement of fluids and electrolytes 428

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is needed. Intravenous replacement is the ideal if circumstances permit, but oral replacement therapy may be just as effective and can be used as an emergency measure in situations where intravenous replacement is not feasible. • Oral rehydration solutions contain a combination of sugar and salt. Sugar facilitates the absorption of fluid and salts in the gastrointestinal tract – as the sugar and salts are absorbed, water follows by osmotic attraction. Oral rehydration therapy should be given freely, or as often as needed, depending on the amount of fluid that has been lost. In gastroenteritis, one cup (250 ml) should be given after each loose stool. Several good oral rehydration solutions are available commercially, but a simple and effective solution can be made at home, as follows: To one litre of water, add 8 teaspoons sugar, ½ teaspoon salt, and orange juice as desired, if available, to improve the taste. Orange juice also acts as a source of potassium and vitamins. Tap water may be used if the water supply is safe, otherwise the water should be boiled. A one-litre cool-drink bottle may be used to measure the water.

• Fluid lost through excessive sweating can be replaced in the same way as gastrointestinal losses. Intravenous replacement with electrolyte solutions is considered the ideal, but oral rehydration therapy can be just as effective, particularly if the dehydration is mild. • Fluid replacement in burns consists of a combination of electrolytes, fluid, plasma (human albumin) and occasionally whole blood. • Careful monitoring is necessary for all patients who are suffering from fluid volume deficit. Monitoring must include vital signs (blood pressure, pulse and temperature), perfusion rate and mental state. If a central venous pressure line is in situ, this must also be carefully monitored. • A careful record of all intake and output must be kept. All fluids taken in or lost must be recorded. • The nurse must ensure that prescribed intravenous replacement fluids are given at the correct rate. • Patients who are suffering from fluid volume deficit are more vulnerable to infection, and care must be taken to avoid cross-infection. • Poor skin perfusion constitutes an increased risk for the development of pressure sores, and measures must be taken to prevent this.

Fluid volume excess Fluid volume excess or hypervolaemia occurs when both water and sodium are retained in abnormally high proportions, and more water is gained than electrolytes. The circulation is overloaded with fluid, leading to excess fluid in the tissues. There are several common causes of fluid volume excess: • Excessive sodium intake • Age-related changes in cardiovascular and renal functions • Some drugs, such as cortisone • Interstitial to plasma fluid shift (burns)

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• Chronic stimulus to the kidney to conserve sodium and water (heart failure) • Abnormal renal function with reduced excretion of sodium and water (renal failure). A common iatrogenic cause of hypervolaemia is huge infusions of intravenous fluid, particularly if large amounts are given rapidly. Patients whose cardiac and/or renal function is impaired are particularly at risk. Elderly patients may easily become overloaded because cardiac and renal function is diminished due to the ageing process. Infants may easily become overloaded if the infusion is given rapidly or if too much fluid is given because the cardiac and renal function is still immature. Assessment

The expected findings/following factors show fluid volume excess: • Neuro-musculoskeletal system: muscle weakness may be present. • Vital signs: hypertension and a full, bounding pulse are indicative of fluid volume overload. • Respiratory system: dyspnoea and respiratory distress, accompanied by an irritating cough, may be noted. These manifestations are due to the presence of excess fluid in the lung tissue, which hampers breathing and irritates the airways, therefore rales, crackles and crepitations may be heard on auscultation. • Gastrointestinal system: there may be weight gain. • Other signs: oedema is frequently noted, with the ankles, feet and sacrum being the common sites. • Ascites and pleural effusion: this may be noted if the fluid overload has built up over a longer period of time. Management

The aim is to facilitate the excretion of the excess fluid by carrying out the following: • Limit fluid intake as ordered. • If the patient is on fluid restriction, make sure that the fluid allocation is spread over the entire 24-hour period. Make allowances for fluid used to take medication and for the fact that some fluid may be taken during the night. Remember also that ice chips are a popular remedy for a dry mouth and are formed from water, which should be taken into account when planning the patient’s fluid intake. Frequent sucking of ice chips, if not regulated, may cause the patient to exceed his or her fluid restriction by a considerable margin. • Limit dietary sodium intake as ordered. Reducing the sodium intake of the patient will reduce fluid retention. • Administer diuretics as prescribed to actively promote the excretion of excess fluid. • Plan the nursing regimen of patients on diuretics in such a way that the diuretic is given during the early part of the day. This will ensure that fluid is excreted during the day when renal function is most efficient. It will also spare the patient the trouble of getting up several times during the night to pass urine. • Ultrafiltration, a process whereby excess fluid is removed using a renal dialysis machine, may be used in patients whose renal function is compromised. • If the patient is dyspnoeic, position him or her in Fowler’s position to facilitate lung expansion. 430

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• Administer oxygen as needed. Careful observation of respiration, skin colour and cough should be carried out. • Monitor intake and output daily. • An increase or decrease in the degree of fluid overload can be detected by: –– checking for pitting, particularly over the sacrum, peri-orbital, shins and ankles –– daily weighing, since gains or losses in fluid can be detected as variations in weight. Weighing should be done at the same time each day and with the same scale, and preferably with the patient wearing clothes of the same type. NB: Measurements of abdominal girth can also be done, especially if the abdomen is distended and the patient has ascites. However, it is important to note that measurements of abdominal girth should always be taken at the same place on the abdomen, with the same tape and with the patient in the same position. Make sure that intravenous infusions are run at the correct rate, and check the rate frequently. Do not increase the rate if the infusion is behind schedule as this can lead to Figure 21.3  Measuring the abdominal girth of a patient further fluid overload in vulnerable patients. It is preferable to reschedule the infusions, taking the deficit into account. Careful control of infusion rates is crucial in infants and small children, since a relatively small increase in rate can lead to fluid overload.

Electrolyte imbalances Electrolyte imbalances are found in many disease states, and the nurse must always be aware of the possibility. Circumstances that commonly cause electrolyte imbalance include the following: • Reduced intake of food • Conditions in which water loss from the body occurs without the loss of salts • Excessive intake of water • Diuretic therapy • Severe illness and/or trauma • Impaired renal function • Immobility • Drugs, for example over-the-counter antacids. Hypernatremia: Sodium excess Hypernatremia refers to an increase in the amount of sodium relative to the volume of water in the body. Hypernatremia is due to reduced water intake and excess loss of water (primary water deficit) or an excess intake of sodium (primary sodium gain). 431

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Primary water deficit may be caused by the following: • Reduced water intake for many days as a result of: –– lack of water –– the inability to drink water –– defective thirst due to altered mental state, psychological disorder or diseases involving the osmoreceptor and or thirst centre. • Increased water loss due to: –– respiratory loss: hyperventilation (eg in cases of laryngo-trachea bronchitis) –– renal loss: central diabetes insipidus –– gastrointestinal loss: vomiting, osmotic diarrhoea –– cutaneous loss: excessive sweating –– profuse watery diarrhoea and hypothalamic tumours may also cause excess loss of water. Primary gain of sodium (Na+) may be caused by the following: • The administration of hypertonic saline may cause hypernatremia in oliguric patients. • Sea water may have been ingested. • The incorrect mixing of infant formula, where insufficient water is used, will result in a feed which is too concentrated and which contains too much sodium. New mothers who are unable to breastfeed should be educated about the correct mixing of infant formula, and it should be emphasised that using more powder will not promote growth but may, in fact, lead to other problems. • Excessive amounts of sodium may be ingested if large amounts of concentrated electrolyte solutions are taken orally. Commercially prepared ‘sports’ drinks often contain high quantities of sodium, and these should be used with great caution. Fluid replacement following sustained physical exertion should be carried out with oral rehydration solutions, which are isotonic and do not contain excessive amounts of sodium. • Unconscious patients who are being tube fed frequently develop hypernatremia because they are unable to drink water and their liquid diet does not provide adequate amounts of plain water. Assessment

The clinical manifestations of hypernatremia include the following: • A dry mouth and mucous membranes • Intense thirst • Pyrexia • Oliguria • Restlessness • Confusion • Convulsions, possibly followed by coma. Laboratory findings show that both serum sodium and serum osmolarity are increased.

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Management

The aim is to reduce the serum sodium levels and to increase intake of water to dilute the sodium: • The patient’s oral intake of water should be increased or isotonic solutions infusions that do not contain sodium should be infused, such as 5% dextrose water as prescribed. • Diuretics may be prescribed to facilitate the excretion of sodium and water, taking care to replace the lost water with plain water or 5% dextrose water. • Nurses must ensure that patients have an adequate intake of plain water, especially those who are being tube fed. • All liquid diets and infant feeds that require reconstitution must be correctly diluted as specified by the manufacturer.

Hyponatremia: Sodium deficit Hyponatremia refers to a decrease in the amount of sodium (real or relative) or the retention of water in the body. Sodium deficit is due to an excess intake of water or to a loss of sodium from the body due to the following: • A very large intake of water due to the following: –– Replacement of lost body fluid with plain water. Using water to replace body fluid lost by excessive sweating, diarrhoea or vomiting may lead to hyponatremia and hypo-osmolarity. Giving large quantities of ice cubes to a vomiting patient as a comfort measure may lead to water excess/water intoxication. Remember that ice cubes are made of water. –– Too much water may have been drunk during a marathon. –– Large tap water enemas or bowel washouts using plain water may lead to the absorption of large amounts of water. –– Fresh-water drowning causes acute water excess as large amounts of plain water are swallowed and absorbed from the stomach of the drowning individual. • A large infusion of dextrose water post-operatively (especially in a young patient with a low muscle mass) • Large infusion of hypotonic lavage fluid due to the following: –– Input of water and organic solutes, with little or no sodium –– A diet deficient in sodium –– Diuretic therapy. Assessment

The clinical manifestations of hyponatremia include the following: • Polyuria • Twitching • Irritability • Confusion • Convulsions and coma. Laboratory findings indicate that both serum sodium and serum osmolarity are decreased.

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Management

Management of hyponatremia is as follows: • The most common method of treating hyponatremia is by restricting the patient’s fluid intake. • Sodium levels must be checked regularly. • In situations where the patient’s sodium levels are severely depleted, the cautious use of small infusions of hypertonic saline may be appropriate, as prescribed by the medical practitioner. • The use of plain tap water for enemas and bowel washouts should be avoided; normal saline is preferable. • Isotonic replacement solutions containing salts should be used to correct fluid losses. • Homemade oral rehydration solutions (see box on page 429) can be very effective in replacing fluids lost from diarrhoea, vomiting or sweating.

Hyperkalaemia: Potassium excess • Hyperkalaemia is potentially life threatening and may be considered to be present if plasma potassium levels are in excess of 5.5 mmol/litre. • Hyperkalaemia occurs in renal failure where potassium is retained, due to the fact that the diseased kidneys do not excrete potassium. • Tissue damage may cause the release of large amounts of potassium from the cells. This occurs following severe burn injuries, massive crushing injuries, polytrauma and severe infections involving significant tissue destruction. • Less commonly, hyperkalaemia is caused by the administration of large amounts of potassium salts orally or intravenously.

Clinical alert! Even if renal function is normal, the rapid intravenous injection of potassium is fatal. Assessment

Patients with potassium excess will often present with the following: • Abdominal cramps and muscle twitching; the muscular symptoms may progress to weakness and paralysis. • Diarrhoea is frequently present. • The pulse is slow and may be irregular. Abnormal ECG findings include distinctive peaked, tent-shaped t-waves, widened QRS complexes and S-t segment depression. Eventually the heart will arrest in asystole. Management

Hyperkalaemia is managed as follows: • Increasing the urine output can reduce potassium levels. A simple way of doing this, provided renal function is normal, is to increase fluid intake, resulting in reduced potassium levels. Diuretics will also promote the excretion of potassium, provided that renal function is normal.

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R

T Peaked tent-like T-wave

P

Q

S

Figure 21.4  ECG trace in hyperkalaemia • Ion-exchange resins containing sodium, such as Kayexalate, are given orally or rectally to remove potassium from the body. In the gastrointestinal tract, the sodium in the resin is absorbed by the body in exchange for potassium, which is drawn out of the gastrointestinal mucosa and binds to the resin. The resin and the excess potassium are then eliminated from the body with the faeces. • In the case of uncontrollable hyperkalaemia associated with compromised renal function, as a last resort haemodialysis can be used to remove excess potassium. • Redistribution of potassium involves shifting it from the extracellular to the intracellular fluid. Insulin with 50% IV dextrose water can be given to this effect in order to prevent profound hypoglycaemia. • Sodium bicarbonate also shifts potassium out of the plasma and into the cells, but this method is not often used because of the risk of metabolic acidosis, which is extremely difficult to reverse. Redistribution of potassium to the intracellular fluid is, however, a temporary measure, as the potassium has not been excreted. The hyperkalaemia may recur once potassium moves back into the extracellular fluid. • The nurse must be aware of the causes of hyperkalaemia, and those patients at risk must be monitored. As the clinical signs and symptoms of hyperkalaemia are somewhat non-specific, the best way of monitoring at-risk individuals is by regular laboratory assessment of serum potassium levels. • A cardiac monitor, if available, can be used to identify the distinctive ECG changes. Daily electrocardiograms will also allow the ECG changes of hyperkalaemia to be identified. • The nurse must also note the precautions to be taken when administering intravenous potassium, as a rapid infusion will be fatal.

Hypokalaemia: Potassium deficit Hypokalaemia is a serious and potentially life-threatening clinical problem, and one that nurses must be able to detect. A serum potassium level of less than 3.5 mmol/litre constitutes hypokalaemia. Contributing factors

• An inadequate dietary intake may cause hypokalaemia. This may be due to conditions such as chronic alcoholism or excessive dieting. 435

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• Gastrointestinal fluid losses through vomiting and diarrhoea, the use of strong purgatives and laxatives, nasogastric drainage and fluid losses from intestinal fistulae or stomas can cause hypokalaemia. • The use of diuretics may cause potassium loss. • Other drugs that cause potassium loss include steroids and some antibiotics. • Renal and metabolic diseases such as Cushing’s disease and acute renal failure also lead to potassium loss.

Clinical alert! Profound hypokalaemia is a common and dangerous feature of the diuretic phase of acute renal failure. Assessment

Patients with hypokalaemia will present with the following: • Fatigue • Muscle weakness • Irritability • Confusion • Abdominal distension, decreased gastrointestinal motility, paralytic ileus and anorexia • Shallow respiration • Arrhythmias. The ECG findings are quite characteristic: multifocal ventricular extra systoles are present, as well as low, flat T-waves, with a U-wave following the T-wave. If hypokalaemia is left untreated, the extra systoles increase in number, and an R-on-T phenomenon, in which an ectopic falls on the T-wave of the preceding normal beat, may trigger ventricular tachycardia or ventricular fibrillation. Eventually the heart will arrest in fibrillation. R

Ventricular extrasystole

P

T Q

U

P

S

Figure 21.5  ECG trace in hypokalaemia 436

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Management

• Management of hypokalaemia is directed at restoring the potassium levels to normal and eliminating the cause of the problem. • Those at risk must be identified and assessed. • Potassium may be replaced orally for mild hypokalaemia and intravenously when severe. • A cardiac monitor for continuous monitoring or daily ECG recording will allow the nurse to detect extra systoles that may be due to hypokalaemia.

Nursing implications When replacing potassium orally, the nurse should bear in mind that potassium salts cause gastrointestinal irritation. Nausea and vomiting, as well as gastric ulceration, may occur. Oral potassium preparations are often unpleasant to the taste, and should not be given immediately prior to a meal. It is a good idea to try to find ways to make the potassium preparation more palatable.

NB! Precautions relating to the intravenous use of potassium • Potassium must never be given undiluted. The administration of a concentrated amount of potassium may cause acute hyperkalaemia, which is invariably fatal. • As a guide, each 20 mmol of potassium should be diluted in 50–100 ml of saline or dextrose water. • Potassium must always be given as an infusion and never as a bolus or intravenous push-in. The rate of the infusion should be monitored. Usually not more than 20 mmol/hr is infused, unless prescribed otherwise. • Although it is acceptable to use a peripheral line for a potassium infusion, a central line is often preferable because it is easier to control the infusion rate and there is far less likelihood that the infusion will extravasate. Extravasated potassium infusion will cause intense local irritation, which may lead to necrosis and ulceration. If a potassium infusion does extravasate, the line should be removed. • Pain, irritation and phlebitis are common in veins used for potassium infusions. Pain can be reduced by slowing the infusion rate and by using more fluid to dilute the potassium. • It is very easy to get potassium chloride ampoules, saline ampoules and sterile water ampoules mixed up because in South Africa the packaging is very similar. The use of potassium chloride to reconstitute injections is a common mistake. To avoid this, always check the fluid ampoule used to reconstitute injections.

Hypercalcaemia: Calcium excess Contributing factors to hypercalcaemia are the following: • Hyperthyroidism • The use of thiazide diuretics • Excessive intake of calcium salts – a potential problem associated with the injudicious use of over-the-counter preparations of calcium salts 437

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• Excessive vitamin D intake, which causes the absorption of excessive amounts of calcium from the GIT, leading to hypercalcaemia (self-medication with multivitamin preparations can cause hypervitaminosis) • Malignancies of bone tissue, such as multiple myeloma or bony metastases, which cause mobilisation of calcium from the bones, leading to hypercalcaemia • Hypercalcaemia is found in renal failure for two reasons: the diseased kidneys do not excrete calcium salts, or the kidneys are not manufacturing active vitamin D, which is needed for the absorption of calcium. In the absence of active vitamin D, the parathyroid glands secrete parathormone, which releases calcium from the bones and raises the level of calcium in the plasma • Individuals who are bedridden suffer from demineralisation of bone, which leads to hypercalcaemia and renal calculi. Assessment

A patient with calcium excess will present with the following: • Neurological: confusion, lethargy and exhaustion • Respiratory: ineffective respiratory movement • Cardiovascular: increased heart rate and BP, bounding peripheral pulses, positive Homans’ sign • Gastrointestinal: decreased motility and bowel sounds, constipation • Renal: increased urine output, flank pain over the kidneys • Skeletal: bone pain and pathological fractures due to demineralisation may be present • Bloods: elevated serum calcium levels, and inverse serum phosphorus levels. Management

The goal of treatment in calcium excess is to eliminate the cause of the problem and to restore normal serum calcium levels. • Ensure that the patient is adequately hydrated. • Administer phosphorus supplements as prescribed to promote the re-uptake of calcium by the bone. • Steroids and calcitonin will also promote the re-uptake of calcium by the bones. Calcitonin may, however, cause an allergic reaction, and steroids need several days to take effect. • Encourage early ambulation of patients to minimise demineralisation of bone. A range of motion exercises should be done on a regular basis for those who are unable to ambulate. • The indiscriminate use of vitamin D or calcium supplements is potentially harmful and should be discouraged.

Hypocalcaemia: Calcium deficit • Hypocalcaemia increases neuromuscular irritability, causing spasticity and rigidity of the muscles. • Calcium deficit may occur if there is a deficiency of vitamin D, as this vitamin is essential for the absorption of calcium from the gastrointestinal tract. 438

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• During pregnancy the body’s demand for calcium is increased, and a deficit may occur if calcium intake is not increased to meet the demand. • Calcium may be lost from the body in diarrhoea, pancreatitis, hypo-parathyroidism and some renal diseases. • Occasionally the parathyroid glands are removed accidentally during thyroidectomy, leading to acute hypocalcaemia. • Overcorrecting metabolic acidosis with sodium bicarbonate can also cause hypocalcaemia. Assessment

• Neurological: irritable muscle twitching • Respiratory: respiratory failure, stridor may be present, possibly heralding laryn-gospasm • Cardiovascular: decreased heart rate and blood pressure • Gastrointestinal: increased motility and bowel sounds, diarrhoea • Musculoskeletal: spontaneous carpopedal spasm, tonic muscle spasms, and rigidity of the limbs and of the abdominal wall Figure: 21.6  Carpo-pedal spasms • Positive Trousseau’s and Chvostek’s signs • Bloods: serum calcium levels are below 2.10 mmol/l. Chronic calcium deficits may lead to rickets, osteomalacia and osteoporosis. Trousseau’s sign Trousseau’s sign is positive if the characteristic hand spasm or carpo-pedal spasm occurs when the circulation to the hand is constricted by the use of a tourniquet or sphygmomanometer cuff. Chvostek’s sign A tap below the temple, where the facial nerve crosses the mandible, produces a spasm of the facial muscles. Management

The treatment of hypocalcaemia is directed at restoring normal serum calcium levels and removing the cause of the problem: • Acute hypocalcaemia causing tetany is corrected by the intravenous administration of calcium salts. Calcium gluconate or calcium chloride may be used. • Chronic calcium deficit can be managed by using oral calcium supplements. • Nurses must be alert for the development of tetany following thyroidectomy. A syringe containing an ampoule of calcium gluconate or calcium chloride should be kept in readiness.

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• Nurses must also be aware of the danger of overcorrecting metabolic acidosis with sodium bicarbonate. Bicarbonate causes metabolic alkalosis, which increases the amount of calcium, which becomes bound to plasma albumin; this reduces serum calcium levels and causes tetany. Calcium salts must be infused slowly. Rapid infusion may cause hypotension, bradycardia and cardiac arrest. Tissue necrosis occurs if a calcium infusion extravasates into the surrounding tissues.

Table 21.6  Summary of major electrolyte disturbances Excess electrolyte (hyper...) Sodium • Caused by ingestion of excess salt, loss of pure water from the body or insufficient intake of plain water • Patient presents with skeletal muscle weakness, dry mucous membrane, thirst, pyrexia, confusion and convulsions, pulmonary oedema, diminished cardiac output, oliguria and dry flaky skin • Treat by restricting sodium intake and increase water intake Potassium • Caused by renal failure, extensive tissue damage, administration of potassium salts • Patient presents with abdominal cramps, muscle twitching, pulse may be slow and irregular, diarrhoea and vomiting, oliguria and low BP. ECG shows typical peaked T-wave • Treat by increasing urine output by administering furosemide (Lasix) as prescribed. Redistribute potassium back into the cells (by administering insulin and dextrose infusion, calcium chloride, sodium bicarbonate as prescribed), dialysis Calcium • Caused by hyper-parathyroidism, renal failure, immobility, excess calcium intake, excess vitamin D intake, bone malignancy and thiazide diuretics. Patient presents with flank pain, renal calculi, GIT upset, lethargy, exhaustion and confusion

Deficit in electrolyte (hypo...) • Caused by a diet deficient in sodium, diuretic therapy, wound drainages, excessive diaphoresis and ingestion of large amounts of plain water • Patient presents with irritability, twitching, confusion, convulsions, coma, shallow respiration, cardiac changes, diarrhoea, and polyuria • Treat by restricting fluid intake or by giving small amounts of hypertonic saline. • Caused by inadequate dietary intake, excessive potassium losses from the body (vomiting, diarrhoea, nasogastric drainage), diuretic use, renal and metabolic disease • Patient presents with fatigue, muscle weakness, decreased GIT motility and shallow respiration. Pulse is weak with extra systoles. ECG shows low, flat T-waves and multifocal ventricular extra systoles • Treat by replacing potassium (NB! See precautions for intravenous replacement)

• Caused by vitamin D deficiency, diarrhoea, pancreatitis, hypoparathyroidism, lactose intolerance, renal disease, and removal or destruction of the parathyroid glands ➙

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Excess electrolyte (hyper...)

Deficit in electrolyte (hypo...)

• Patient presents with disorientation, lethargy, coma, ineffective respiratory movement, increased heart rate and BP, decreased motility and bowel sounds, and increased urine output • Treat by administering diuretics, continuous cardiac monitoring, ensuring adequate hydration and administration of phosphorus supplements to promote calcium re-uptake into the bones, calcitonin may be given

• Patient presents with tetany, carpo-pedal spasm, muscle rigidity, stridor, and laryngospasm, decreased BP, increased gastrointestinal motility and bowel sounds. Pulse may be irregular with extra systoles • Acute hypocalcaemia is treated by the intravenous administration of calcium salts. Chronic hypocalcaemia is managed with oral calcium supplements, given together with vitamin D precautions for seizure

(NB! Watch out for any allergic reaction.)

Disturbances of acid–base balance Disturbances in electrolyte, fluid or acid–base balances seldom occur alone, and when they do, they disrupt normal body processes. Acid–base disturbances occur in many disease states and it is important to recognise them, as organ function is adversely affected by alteration in the pH of body fluids. When there is loss of body fluids because of burns, illnesses or trauma, the patient is also at risk for electrolyte imbalances. In addition, some untreated electrolyte imbalances (eg potassium loss) result in acid–base disturbances.

Blood gases Arterial blood gas (ABG) analysis is used to measure the pH and the partial pressures of oxygen and carbon dioxide in arterial blood. Usually arterial blood is used, although venous blood may be used in situations where the levels of oxygen and carbon dioxide are known to be normal, and are thus not a cause for concern. If it will be some time before the specimen can reach the laboratory, it should be kept on ice to preserve gas levels. ABG has six components – pH, PCO2, PO2, oxygen saturation, base excess and HCO3– – that are measured. Deviation from a normal value indicates that the patient is experiencing an acid–base imbalance.

Precautions relating to the taking of arterial blood samples • The radial artery is the preferred site, as it is easy to palpate and has good collateral supply. The femoral artery may be used if the radial artery is not accessible, but great care must be taken to prevent damage and bleeding at the site. The brachial artery should not be used because of the risk of damaging the radial nerve, which passes close to the artery in the antecubital fossa. • It is very important to apply direct pressure for at least 10 minutes after arterial puncture to obtain haemostasis and longer if the femoral artery has been used. • Arterial puncture is painful. Although good technique can reduce pain, the patient should be warned that the procedure would hurt a little.

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Table 21.7  Important values in a blood gas result Value

Significance

Normal value

pH

Shows acidity < 7.35/alkalinity of body fluids > 7.45

7.35–7.45

PCO2

Shows the partial pressure of carbon dioxide in the blood and reflects the depth of pulmonary ventilation

4.4 + 0.5 kPa (34 + 4 mmHg) on the Witwatersrand 5.3 + 0.5 kPa (40 + 4 mmHg) at sea level

PO2

Shows the partial pressure of oxygen in the blood

9.0 + 11 kPa (68–83 mmHg) on the Witwatersrand 10.5–13.3 kPa (80–100 mmHg) at sea level

HCO3–

Shows the level of bicarbonate in the blood. It is the major component of acid–base balance produced by the kidneys to maintain acid–base environment

19–23 mmol/litre on the Witwatersrand 22–27 mmol/litre at sea level

Base excess

The metabolic component of the acid–base balance is reflected in the base excess. This is a calculated value derived from blood pH and PaCO2. It is defined as the amount of acid required to restore a litre of blood to its normal pH at a PaCO2 of 40 mmHg. The base excess increases in metabolic alkalosis, and decreases (or becomes more negative) in metabolic acidosis, but its utility in interpreting blood gas results is controversial

–3 to +1 mmol/litre

Note: Figures may vary somewhat, depending on the authority used.

Units of measurement The unit of measurement for blood gas estimations is the kilopascal (kPa). To convert kilopascals to mmHg, the kPa figure should be multiplied by a factor of 7.5, or to convert pressures to kPa, divide mmHg by 7.5. Differences between sea level and the Witwatersrand are due to differences in atmospheric pressure, which affects the amount of gas that is able to dissolve in the plasma. The higher the atmospheric pressure, the greater the amount of gas that dissolves in the plasma, and vice versa. Because levels of carbon dioxide are higher at sea level, levels of bicarbonate are increased.

A disturbance of acid–base balance may cause acidosis (excess acid), or alkalosis (excess base). 442

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Respiratory acidosis Respiratory acidosis occurs when the lungs cannot remove enough carbon dioxide (CO2). There is hypoventilation resulting from a primary respiratory problem, and may be due to a variety of pulmonary problems. Carbon dioxide thus builds up in the bloodstream, forming carbonic acid, which causes the pH to drop. Any condition that reduces gas exchange in the lungs, such as pneumonia, atelectasis, pneumothorax or depression of the respiratory centre, will lead to respiratory acidosis. Causes

• Airway obstruction due to laryngeal oedema • Respiratory depression due to medication • Lungs and chest-wall defects (eg pneumothorax, pulmonary oedema). Assessment

The patient presents clinically with the signs and symptoms of respiratory insufficiency: dyspnoea, cyanosis, productive cough, tachypnoea and disorientation. Definitive evidence of respiratory acidosis is obtained from blood gas estimation. Table 21.8  Blood gas findings in respiratory acidosis pH

Below 7.35

PCO2

> 45 mmHg

PO2

< 80 mmHg, depending on the cause of acidosis

SaO2

Normal or < 95 %, depending on the cause of acidosis

HCO3–

Normal if early respiratory acidosis, > 26 mEq/L if kidneys are compensating, depending on the cause of acidosis

Base excess

Below –3, but not markedly so, due to renal compensatory mechanisms. Renal retention and excretion of hydrogen ions help to maintain the ratio of base to acid close to the normal range

Management

Treatment of respiratory acidosis is directed at improving the patient’s gaseous exchange. • Breathing must be stimulated, excess secretions cleared and mechanical ventilation commenced if indicated. • In severe acidosis (if the pH is below 7.10), sodium bicarbonate can be used cautiously, bearing in mind the risks of over-correction and the resulting metabolic alkalosis. • The nurse must be alert for respiratory acidosis in patients with respiratory problems, therefore measures should be instituted, for example through correct positioning, to help the patient breathe more effectively and thus maintain adequate gas exchange. • Serial blood gas estimations should be done in the case of serious respiratory difficulties. Respiratory acidosis, coupled with a PO2 of less than 55 mmHg and a PCO2 of more than 50 mmHg, is an indication for mechanical ventilation.

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Metabolic acidosis In metabolic acidosis there is excess production of acids in the body, or the body may be unable to excrete acids via the kidneys. Excess acid production occurs in diabetic keto-acidosis, starvation and high-fat diets where the breakdown of fats produces large amounts of acid metabolites. In the case of tissue anoxia, lactic acid is produced. Other causes of excess acid production include pyrexia, hepatitis and general anaesthesia. Metabolic acidosis occurs in renal failure because acids are not excreted. Loss of bicarbonate will also lead to metabolic acidosis. Loss of bicarbonate may occur in diarrhoea, and in pancreatic as well as duodenal fistulae. Metabolic acidosis may also be due to the administration of large amounts of acid substances, such as ammonium chloride or aspirin. The body compensates for metabolic acidosis by stimulating respiration, thereby enabling some of the acids to be excreted. Assessment

In addition to the signs and symptoms of the causative problem, the patient presents with the following clinical manifestations: • Deep sighing respiration, known as Kussmaul’s breathing, due to respiratory stimulation • Dyspnoea on exertion • Markedly acid urine if renal function is normal • Mental confusion and alteration in level of consciousness • Possible disturbances in cardiac rhythm. Table 21.9 Blood gas findings in metabolic acidosis pH

< 7.35

PO2

Normal, or may be increased due to respiratory stimulation

PCO2

Normal, or < 35 mmHg if the lungs are compensating

HCO3–

< 22 mEq/L

Base excess

Markedly below –3

Management

Treatment is aimed at alleviating the underlying cause of the acidosis: • Restore blood sugar to normal, together with rehydration, in the case of diabetic keto-acidosis. • Give oxygen therapy and intravenous dextrose to correct lactic acidosis. • The metabolic acidosis of renal failure is usually managed by dialysis. • General measures include the correction of fluid and electrolyte imbalances. In particular, imbalances of sodium, potassium and chloride should be corrected. It is usually preferable to allow metabolic acidosis to correct itself once therapy for the primary cause has been instituted. • In severe cases, however, where the pH is less than 7.10, the cautious use of sodium bicarbonate may be justified.

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• Nurses must be aware of conditions that lead to metabolic acidosis, and monitor at-risk patients accordingly. Regular blood gas estimations, as determined by unit protocol or as requested by the doctor, will provide precise information. • Nurses should ensure that patients are adequately nourished and hydrated, as this will facilitate the maintenance of acid–base balance, as well as promoting the maintenance of fluid and electrolyte balance. • Cardiac rhythm should be monitored in the acidotic patient because arrhythmias are common in acidosis. A cardiac monitor is useful. Alternatively, a daily ECG and regular monitoring of the pulse can be carried out.

Respiratory alkalosis Respiratory alkalosis occurs when excess amounts of carbon dioxide have been blown off during hyperventilation. This loss of carbon dioxide and water effectively means loss of acid, because carbon dioxide and water are formed from carbonic acid. Hyperventilation may be due to anxiety, hysteria, intentional over-breathing, raised intracranial pressure or mechanical ventilation. The body compensates for the problem by excreting bicarbonate ions via the kidneys, making the urine more alkaline. Hyperventilation due to anxiety or hysteria is often self-limiting: the drop in CO2 causes the individual to faint, and normal breathing re-establishes itself during the brief period of unconsciousness. Assessment

• The patient presents with deep, rapid breathing. • Tetany and carpo-pedal spasm may occur. An alkaline pH causes calcium to bind with plasma albumin, effectively reducing serum calcium and causing tetany. Table 21.10  Blood gas findings in respiratory alkalosis pH

Above 7.45

PCO2

Markedly decreased

PO2

Normal, or may be increased due to over-breathing

HCO3–

Decreased due to renal excretion of bicarbonate

Base excess

Above +1, but not markedly so due to renal compensatory mechanisms. Excretion of bicarbonate helps to maintain the normal ratio of base to acid

Management

Management is directed at eliminating the cause of the hyperventilation. • Where hyperventilation is due to anxiety or hysteria, the individual can be asked to breathe into a paper bag, which forces the individual to rebreathe his or her own carbon dioxide, which restores carbon dioxide levels. If the patient is too anxious to tolerate a paper bag, the nurse should try to get him or her to relax and breathe more slowly. • Using carbogen gas, a combination of carbon dioxide and oxygen, given via an oxygen mask can treat respiratory alkalosis due to a neurological problem. 445

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• Hyperventilation due to mechanical ventilation can be corrected by decreasing the rate and/or the tidal volume. Alternatively, adding more tubing can increase the dead space on the ventilator. • Correction of fluid and electrolyte balance is necessary in longstanding hyperventilation, as a great deal of water vapour is lost during deep heavy breathing. • Nurses must be aware of the possibility of hyperventilation in anxious patients, or in the relatives of very sick patients, and be ready to apply a paper bag. This type of reaction may also occur when patients or their relatives have been given bad news. • Over-ventilation in patients who are being mechanically ventilated can be detected by means of regular blood gas estimations.

Metabolic alkalosis In metabolic alkalosis, the problem is that of an excess of base. This may be due to loss of acid or to the ingestion of large amounts of base. Loss of acid may occur when large amounts of gastric acid have been lost. Potassium depletion may also be associated with metabolic alkalosis. Excess ingestion of bicarbonate is often an iatrogenic problem following the administration of large amounts of sodium bicarbonate. An overdose of bicarbonate may also follow indiscriminate self-medication with alkalising agents such as antacids. In metabolic alkalosis, the body compensates by retaining acids and excreting bicarbonate, making the urine more alkaline. Carbon dioxide is retained in the lungs and breathing becomes slow and shallow, with periods of apnoea. Assessment

The following occurs: • Breathing is slow and shallow. • Tetany and carpo-pedal spasm, progressing to convulsions, may be present due to the alkalinity of body fluids. • Muscle tone is increased and all tendon reflexes are exaggerated. Table 21.11  Blood gas findings in metabolic alkalosis pH

Above 7.45

PCO2

Increased due to slow, shallow breathing that promotes the retention of carbon dioxide

PO2

Decreased due to hypoventilation

HCO3–

Markedly increased

Base excess

Markedly above +1, as the ratio of base to acid has increased considerably

Management

Management consists of the following: • Correct the underlying cause, and administer solutions containing chloride ions. • Increasing the levels of chloride promotes excretion of bicarbonate by the kidneys.

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• Potassium replacement may also be necessary as potassium becomes depleted in alkalosis. Any other fluid and/or electrolyte imbalance must be corrected. • It is worth noting that metabolic alkalosis is difficult to treat, and several days are needed to correct the problem. For this reason the condition should be prevented if at all possible. • It is essential to avoid the overuse of sodium bicarbonate during resuscitation. In fact, it is usually better to under-correct and to allow the body to restore acid–base balance on its own. • Fluids containing chloride should be used to replace fluid lost during gastric suction. • The public should be educated to avoid inappropriate self-medication with antacids. • If the problem is related to the build-up of carbon dioxide in a ventilated patient, the problem is not actively corrected, but allowed to reverse itself naturally as the patient’s condition improves. Table 21.12  Summary of blood gas findings in acid–base disturbances Respiratory

Respiratory

Metabolic

Metabolic

acidosis

alkalosis

acidosis

alkalosis

pH

Below 7.35

Above 7.45

Below 7.35

Above 7.45

PCO2

Increased

Decreased

Decreased

Increased

PO2

Decreased

Normal to increased

Increased

Decreased

HCO3–

Normal or slightly decreased

Decreased

Grossly decreased

Grossly increased

Base excess

Below –3

Above +1

Markedly below –3

Markedly above +1

Recording of intake and output

An accurate record of the patient’s intake and output is essential in order to monitor fluid status, which will also give an indirect indication of electrolyte and acid–base balance. The amount and type of all fluids taken in or lost should be recorded. The intake/output record should be accurate enough to enable it to be used as an aid in the diagnosis and treatment of fluid, electrolyte and acid–base disturbances. All patients who are potentially at risk for any imbalances should have their intake and output recorded. The following categories of patients are particularly vulnerable and should automatically have intake and output recorded. They are patients: • who have had major surgery • with burn injuries • with other serious or extensive injuries • with acute renal failure • with oliguria • with congestive cardiac failure 447

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• • • • • •

with abnormal or excessive loss of body fluid on diuretic therapy with inadequate intake of food or fluid who are unconscious with confusion and mental disorientation who need artificial feeding. The specific objectives of intake/output monitoring are as follows: • To assess the patient’s fluid status • To monitor urine output and renal function • To supervise the patient’s fluid intake – this is particularly important if the patient’s intake is restricted or an increased intake has been prescribed • To monitor the type of fluid that the patient is taking, particularly if nourishing fluids have been prescribed.

Wherever possible, the patient should be educated regarding the recording of his or her intake and output. The patient should be encouraged to remember what he or she has eaten or drunk. The patient should also be aware that all output is measured, which means that he or she needs to request a bedpan/urinal from the staff. If the recording of intake and output is being carried out at home, the patient will need to be educated regarding the use of the charts, the volumes of common household utensils and methods of measuring urine output. The family must also be included in this education. The nurse should check the recording of intake and output at regular intervals, particularly after each meal and after refreshments. Intake and output records should be updated at the end of each shift. Most institutions require the totalling of intake and output after each 12-hour period (eg at 07h00 and 19h00). Often the balance between intake and output must be worked out. This daily balance indicates whether the patient is retaining or losing fluid overall. All output must be recorded. Output such as vomitus, liquid faeces, wet beds and wound drainage must be estimated if measurement is not possible. Ensure that all members of the multidisciplinary team are aware that intake and output are being recorded. Make sure that this fact is recorded in the patient’s care plan. It may be useful to place a sign by the bedside. The nurse should be familiar with the volume of common eating and drinking utensils, as this will make accurate recording easier. Most cool-drink bottles and cartons show the volume. • Teacup: 120–150 ml • Coffee mug: 150–180 ml • Porridge bowl: 200–250 ml • Water glass: 150–180 ml Unsatisfactory intake or output should be reported. The recording of intake and output is not the only parameter that requires monitoring. It is important for the nurse to note all clinical manifestations that could relate to fluid, electrolyte and acid–base balance: 448

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• • • •

Blood pressure, pulse, temperature and respiration Level of consciousness and mental state Skin turgor and perfusion – note the presence of oedema Short-term fluctuations in body weight.

Intravenous therapy Intravenous therapy is the administration of fluids, electrolytes or nutrients directly into the circulation via a vein. The indications for intravenous therapy are as follows: • The replacement of lost body fluids • The replacement of electrolytes in order to correct electrolyte imbalances • The provision of essential nutrients such as glucose, amino acids, lipids and vitamins • Where oral and/or enteral nutrition is inadequate or contraindicated • As a vehicle for the administration of medications directly into the circulation • To provide access to the circulation in case of emergency. Management of a patient on intravenous therapy

Intravenous therapy is invasive and as such has a potential for infection. The nurse must ensure that the procedure is explained to the patient and significant others. Where necessary, a consent form may be signed, for example patients who are Jehovah’s Witnesses in the case of blood transfusion. The procedure for putting up a drip is sterile, with the skin being thoroughly cleansed before the drip can be put up. The doctor must prescribe intravenous therapy and the following must be clearly stated: • The type of fluid – this will also assist in the choice of the giving set • The amount to be infused • The time over which it is to be infused. This is stated in terms of rate (ie the number of drops per minute) and also ensures that fluid is not rushed into the system to cause fluid overload. Aspects to be borne in mind in preparing for an intravenous therapy

• • • • • • • • • • •

The giving set/drip set must be sterile and appropriate for the fluid to be given. The fluid to be infused must be clean and clear, with no floating particles. The container must be sealed and patent. Always check the fluid to be infused for correctness against the prescription. Always check the expiry date on the vacolitre. Check the identity of the patient to ensure that the correct patient is infused. Blood must be correctly labelled and kept in the refrigerator until the time of administration. Avoid introducing air into the intravenous lines. Replace each vacolitre in time before it is completely empty. Intravenous therapy is uncomfortable and in some instances outright painful; therefore it is important to explain the procedure to the patient to elicit co-operation. Where possible, the patient should be kept in bed to minimise the chances of displacing the needle and causing the drip to infiltrate into the tissue. A vein is used and, even though this can be any vein in the body, the usual part of the body used is the forearm or the back of the hand. The point of insertion is secured with a plaster 449

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or a bandage. Depending on the location, a splint may be used to further minimise movement in the vicinity, especially where the insertion is near a joint. In children, the doctor may even prescribe restraints to be applied to ensure stability of the limb. Care of a patient on intravenous therapy

• The limb or part used must be supported to ensure stability. • Monitor the flow of the infusion. In some instances, an infusion pump may be used to regulate the flow. • Vital signs, including weight, must also be monitored to identify circulatory overload and possible infection for early intervention. • Observe the area of needle insertion and the area surrounding it. Oedema, inflammation and pain may be indicative of infiltration. • Record intake and output, and report on the progress of the therapy. • In cases where intravenous therapy is used for administration of medication, this must be prescribed and, if added in the vacolitre, the vacolitre must be labelled accordingly. • Prevent contamination of the intravenous set by observing infection-control measures and sterile techniques. • The prevention of related complications such as fluid overload, infection and air embolism is an integral part of care of patients on intravenous infusion. • Monitor and ensure correct infusion rate to avoid fluid overload or deficit. • Observe vital signs quarter-hourly or frequently for patients having a blood transfusion to monitor for adverse reactions. • Clinical signs of possible electrolyte imbalance, such as mental changes like confusion and drowsiness, especially in an elderly patient, must be noted. • Irregular monitoring of infusions may result in air entering the lines or the infusion extravasation. • Double check and validate all infusions, substances or medications to be added to the infusion. • Principles of aseptic technique to be adhered to at all times to prevent contaminating the insertion site.

Conclusion In order to provide adequate nursing care of patients at risk of and/or with common clinical problems related to fluid, electrolytes and acid–base imbalances, nurses should detect signs of imbalances early and treat them promptly in collaboration with the multidisciplinary health team, especially those that may result in life-threatening complications.

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Suggested activities for students Activity 21.1 Answer the following questions to test your knowledge of this chapter: 1. Electrolytes are substances that, when in solution, dissociate into: a. electrically charged particles called ions b. electrically charged particles called cations c. electrically charged particles called anions d. electrically charged particles called urea. 2. The most prevalent electrolyte in the extracellular fluid is: a. chloride b. magnesium c. potassium d. sodium. 3. The major source of water loss from the body is: a. insensible skin loss b. insensible respiratory loss c. urine d. sweat. 4. Hypervolaemia can cause: a. full bounding peripheral pulses, anuria and oedema b. hypertension, bradycardia and oedema c. hypotension, full bounding peripheral pulses and oedema d. hypertension, full bounding peripheral pulses and oedema. 5. The typical clinical manifestations of severe fluid volume deficit include: a. thirst, loss of body weight and fatigue b. cold and clammy skin, weak and rapid pulse, and pronounced hypertension c. cold and clammy skin, weak and rapid pulse, and pronounced hypotension d. headaches, weak and slow pulse, and oliguria.

Activity 21.2 State if the following statements are true or false: 1. The principal treatment of hypernatremia is fluid restriction. 2. Potassium is the main cation of the extracellular fluid responsible for the normal excitability and stimulation of nerves. 3. The patient’s medication history is not important when assessing patients for disturbances of fluids, electrolytes and acid–base balance. 4. In infants younger than 18 months, significant loss of body fluids causes a sunken fontanelle.

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chapter

22

Mobility and exercise need

Learning objectives On completion of this chapter, the student should be able to do the following: • Accurately assess movement, muscle tone and co-ordination. • Identify patients who are at risk for the development of pressure sores, deep vein thrombosis and hypostatic pneumonia. • Effectively implement nursing interventions designed to prevent the complications of immobility, which comprise: –– care of pressure areas, including the use of special bed accessories and mattresses –– utilising mobility aids such as walking frames, crutches, monkey chains, etc –– maintenance of good body alignment and maintenance of functional position of the joints, including the use of splints and other aids –– maintenance of optimum lung expansion and removal of excess bronchial secretions by coughing and expectoration –– carrying out of passive range-of-motion exercises designed to preserve mobility at the joints and to prevent venous stasis –– mobilisation of patients, depending on their physical condition and activity tolerance –– prevention of urinary stasis by the judicious use of fluids, unless this is contraindicated –– prevention of constipation through diet, fluids and gentle aperients if necessary –– assisting with active and passive exercises.

Key concepts and terminology Active exercise: Independent movement of all joints by the patient through a complete range of motion. Atelectasis: Partial or complete collapse of the lung or lobes of the lung. Atrophy: Decrease in muscle size and bulk due to disuse. Basal metabolic rate: Minimal energy required to maintain physical and chemical processes within the body. Contracture: Permanent shortening of the muscle, leading to limited joint mobility. Decerebrate position: An abnormal body posture where the muscles are tight and rigid, the arms and legs are held straight with the toes pointing downwards, and the head and neck are arched backwards. ➙

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Decorticate position: Abnormal posture where the person is stiff with bent arms, clenched fists facing downwards, and legs held straight. Decubitus ulcer: Also known as pressure sore or bedsore. Embolus: A clot that has moved from its point of origin, causing an obstruction elsewhere in the circulation. Passive exercise: The movement by another person of the patient’s joints through the full range of motion. Range of movement: Maximum movement possible for a specific joint. Thrombophlebitis: Inflammation of a blood vessel wall in the area of a clot. Thrombosis: Formation or presence of a blood clot in a blood vessel. Thrombus: Blood clot found in a blood vessel.

Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy and physiology of the musculoskeletal system • Physical science in relation to movement of, especially, joints.

Medico-legal considerations The major medico-legal considerations include the following: • Pressure sores that are as a result of poor nursing care, hence the demand for an incidence statement should a patient develop pressure sores under the care of nurses • Hypostatic pneumonia, urinary tract infection and contractures. The scope of practice of the registered nurse authorises the nurse to carry out the following interventions related to the maintenance of mobility: • Promotion of exercise, rest and sleep with a view to the healing and rehabilitation of a patient • Facilitation of body mechanics and prevention of bodily deformities in a patient with a potential to develop deformities • Protection of the skin and the maintenance of sensory function in a patient.

Key ethical considerations • Mobility needs are part of basic nursing care and it should never be necessary for the doctor to prescribe any aspect of this level of care, as these decisions are the professional prerogative of the nurse as part of the independent function. However, this does not exclude discussion and collaboration with the doctor. • A pressure sore can be considered to be an indicator of neglect and poor nursing care. ➙

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• Complications such as hypostatic pneumonia or urinary infections may prolong the patient’s stay in hospital and may lead to the death of the patient. • The nurse’s duty to take due care is very clear in meeting the need for mobility and preventing the complications of immobility.

Essential health literacy • Education regarding the benefits of exercise for all body systems is an important aspect of health education. People of all ages should be encouraged to do some form of exercise in order to promote physical fitness, cardiovascular health and the maintenance of optimum body weight. • As part of their role in the general promotion of exercise and fitness, nurses should also be encouraged to participate in some form of physical exercise.

Introduction The body is designed as a dynamic, moving machine, able to perform a variety of activities and maintain a desirable body posture. Movement is therefore an important aspect of human function and health. Movement and exercise have important benefits for the body while immobility has a number of harmful effects on the body. Physical movement has two functions: 1. To enable individuals to carry out the normal activities of daily living. 2. To be a source of pleasure. Many people undertake physical activities such as exercise in order to experience the sense of wellbeing that is associated with it. The nurse may use a variety of skills to support the patient in fulfilling these provisions. Interventions could include the following: • Assessing mobility and at-risk status for pressure sores and deep vein thrombosis • Turning of patients and position changes to relieve pressure on pressure areas • Use of splints as well as the positioning of joints and limbs • Carrying out a range-of-motion exercises • Logrolling of patients with spinal injuries, or following spinal surgery • Appropriate application of various bed accessories and aids to facilitate mobility • Encouraging breathing exercises and coughing • Mobilisation of patients and assisting with physiotherapy. Since the meeting of the need for mobility and exercise is part of basic nursing care, the development of complications and deformities as a result of immobility can frequently be attributed to inadequate or even negligent nursing care. Although it should also be said that some patients would develop problems despite good care, conscientious nursing and the implementation of measures to prevent the complications of immobility will assist in minimising any adverse outcomes.

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Nursing implications • Turning and changing of position is the most important aspect in the prevention of pressure sores. Rubbing is not necessary, and may be contraindicated because it causes friction, which may lead to skin breakdown instead of preventing it. The application of rubbing lotions may also cause dampness of the skin, which may also contribute to skin breakdown. • Chest physiotherapy by deep breathing, chest percussions and limb exercises must be continued throughout the 24-hour period. If the physiotherapist is not available, the nurse should continue with the exercises. • Poor personal hygiene and poor care of the skin may predispose the skin to breakdown. • Lack of attention to the maintenance of good body alignment and functional position of the joints may lead to contractures and deformities.

Mobility and exercise need Exercise has a positive effect on all systems of the body, especially the cardiovascular and respiratory systems as well as metabolism.

The benefits of exercise • Muscle tone is improved. • Cardiovascular efficiency and cardiac reserve are increased. • Oxygenation and pulmonary efficiency are improved. • Digestion is enhanced. • The utilisation and metabolism of foodstuffs are improved. • Mental alertness is increased. • Work and stress tolerances are increased. • Sleep is sounder. • Cholesterol levels are decreased. • Haemoglobin levels are increased. • The amount of fatty tissue in the body is decreased. • It feels good. Exercise induces a pleasant feeling due to the secretion of endorphins, and exercising is also a healthy way to relax.

Activities of daily living The activities of daily living are movements and activities that an individual must be able to carry out sometimes unassisted in order to go about his or her day-to-day tasks. The activities of daily living include the following: • Washing and dressing • Eating and drinking • Cooking and cleaning • Walking, sitting and getting in and out of a bed or chair • Carrying and lifting various articles at home or at work 455

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• Using various items of office equipment or home appliances. In order to be able to perform these activities of daily living, a variety of motor skills are required, such as the following: • Moving and lifting the head, hands, feet individually and together, as well as lifting the whole body • Grasping, lifting and throwing objects • Rolling over and turning • Sitting, lying, standing and walking. The motor skills required to perform the activities of daily living are important in nursing, as these are the movements that must be encouraged when promoting independence, particularly during the rehabilitative phase.

Factors affecting mobility Growth and development • Newborns have mainly reflexive movements which are generally in flexion; however, all joints can be moved through all ranges of motion. Gross motor development occurs first, followed by fine motor skills. • School-going children develop further motor skills including balancing, for example on a bicycle. Physical education and sports at school assist in the development of mobility, and promote a healthy lifestyle with the benefits of exercise. • Teenagers need to be encouraged to exercise, as many are involved in sedentary activities such as computer games. Schools should discourage the use of shoulder bags for heavy books as these can adversely affect the posture by placing increased strain on one side of the body. • Advancing age affects bones, joints and muscles. Bones lose mass and density, and thus become fragile, placing the patient at risk for easy fractures. Compression fractures of the vertebrae cause alteration in posture (which becomes forward leaning and stooped) and therefore alteration in gait and balance. Muscle tone also decreases, resulting in decreased ability to perform strenuous activities. Joints lose flexibility and may develop arthritic changes, causing pain and decreased movement. Nutrition • Good nutrition is essential for optimal musculoskeletal functioning and mobility. • Under-nutrition results in muscle weakness and fatigue. • Lack of minerals such as calcium can result in osteoporosis and subsequent fractures. • Obesity places joints under excess stress, resulting in decreased ability to move. Obesity also puts strain on the cardiovascular and respiratory systems, causing decreased activity tolerance and thereby affecting the person’s ability to move and exercise. Environmental factors • Environmental temperature and level of humidity affect the desire to exercise and move around generally. Most people avoid as much activity as possible in hot, humid 456

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weather. Fluid intake needs to increase in these circumstances, and replacement of fluid and electrolytes needs to be adequate while exercising. Very cold weather may also decrease motivation to be active as one tends to want to stay warm indoors. • The safety of the neighbourhood is also a factor as people need a safe place to exercise. Walking is an excellent form of exercise, but this will be less to nonexistent if the area is not safe. • The availability and access to gyms also plays a role. Teenagers need to be encouraged to exercise rather than play computer games.

Prescribed limitations • Health status may determine the amount and type of exercise a person may do, such as cardiac or respiratory conditions. • Patients in plaster of Paris or traction will be temporarily less mobile and may require rehabilitation to regain full mobility. • Neuromuscular disorders, such as muscular dystrophies or disorders following a head injury, stroke or spinal injury, will also decrease the person’s mobility. • Sensory conditions such as decreased vision will affect the person’s ability to mobilise freely and without assistance.

Nursing assessment of mobility A general assessment of the patient’s mobility is essential in order for the nurse to identify any limitations to movement and to fully ascertain the extent to which the patient will require assistance in carrying out the activities of daily living. Following are some aspects which the nurse should assess when carrying out a general survey of a patient’s mobility.

Physical assessment • Ask the patient to rise from a lying position to a sitting position on the edge of the bed or examination table. Normally the patient should be able to do this unaided. If the patient is suffering from muscle weakness, he or she may push on the bed, or pull him- or herself up by means of the cot sides or other handy items of furniture. • Observe the appearance of the joints for swelling, redness, deformities or increased temperature over the joint. • Palpate for signs of tenderness. • Observe the range of movement the patient can achieve with each joint. • Ask the patient to stand up out of a chair. Normally the patient should be able to do this unaided. If muscles are weak, the patient may push him- or herself up with the hands, or may lean forward before rising. • The nurse should observe the amount of assistance needed by the patient to move in or out of bed. The nurse should note whether the patient can turn in bed unaided or not, as well as sit up in bed. • The nurse should assess the patient’s gait by asking the patient to walk a short distance. The nurse should note the following: –– the steadiness of the gait –– balance and co-ordination while walking 457

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–– –– –– –– ––

posture any curvature of the spine whether the feet and legs are lifted normally or if the patient just shuffles along whether the steps are appropriate or too short activity tolerance – whether the patient easily tires or becomes breathless.

Nursing history • Ask the patient about the ability to perform normal activities of daily living. • If not, what are the restrictions and to what extent? • Does the patient experience any form of activity intolerance? • If yes, to what extent? • Does the patient follow any exercise programme? • What activities does the patient normally do, such as walking up stairs? • Find out about the patient’s medical history on conditions that may affect the patient’s ability to mobilise.

Meeting the mobility needs of the patient If the patient is unable to meet his or her own activity needs, the nurse must do this for the patient. This is not merely a comfort measure, as there is some evidence to suggest that exercise helps to promote recovery by stimulating the immune system and increasing the secretion of growth hormone, which is required for healing and rebuilding of tissues.

Active exercise This is exercise that is actively carried out by the patient. In the case of patients who are not fully mobile, or who are able to carry out only a limited number of activities, the nurse should encourage them to do as much for themselves as possible. It may be helpful to refer such patients to the physiotherapist, who can work out a specific programme of active exercise for them. Once an exercise programme has been worked out for a patient, the nurse should acquaint him- or herself with it and actively help and encourage the patient to carry it out. Passive exercise Passive exercise is done by the nurse or physiotherapist where the patient is unable to carry out the movements, or is paralysed or unconscious. When carrying out passive exercise, the following principles should be borne in mind: • Unused muscles degenerate and atrophy. • Bone and skin also degenerate and atrophy with disuse. • All joints have a specific range of motion (ROM). • Brute force should never be used in moving a limb, and the natural limitation of movement at the joints should never be exceeded. • Regular passive exercise prevents stiffness and contractures, but only active exercise can preserve muscle tone and strength.

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Joint movements • Flexion: Decreasing the angle of a joint – brings the two bones closer together, such as bending the elbow. • Extension: Increasing the angle of a joint – increases the distance between the two bones, such as straightening the elbow. • Rotation: Movement of a bone around its longitudinal axis, such as shaking the head. • Abduction: Moving a limb away from the midline of the body, such as standing with legs apart. • Adduction: Moving a limb towards the midline of the body, such as crossing the legs. • Circumduction: Combination of flexion, extension, adduction and abduction seen in ball-and-socket joints, such as when bowling a ball in cricket. • Pronation: Moving the bones of the forearm to turn the palm of the hand to face down. • Supination: Turning the bones of the forearm so that the palm of the hand faces upwards. • Inversion: Internal rotation of the foot. • Eversion: External and upward rotation of the foot.

Toes: Flexion and extension

A. Flexion of the toes

B. Extension of the toes

Ankle: Flexion and extension

A. Flexion at the ankle

B. Extension at the ankle ➙

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Knee: Flexion and extension

A. Flexion at the knee

B. Extension at the knee

Hip: Flexion and extension; abduction, adduction and circumduction

A. Flexion at the hip

C. Abduction at the hip

B. Extension at the hip

D. Adduction at the hip

E. Circumduction at the hip ➙

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Fingers: Flexion and extension

A. Flexion at the fingers

B. Extension at the fingers

Wrist: Flexion and extension; supination and pronation

A. Flexion at the wrist

B. Extension at the wrist

C. Supination at the wrist

D. Pronation at the wrist

Shoulder: Flexion and extension; abduction, adduction and circumduction

A. Flexion at the shoulder    B. Extension at the shoulder

C. Abduction at the shoulder ➙

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D. Adduction at the shoulder

E. Circumduction at the shoulder

Figure 22.1  Movement at the joints

Relaxation Relaxation is as important as exercise, because relaxation gives the mind and body a break, as well as a change in pace.

Physiological response to relaxation • Decreased activity of the sympathetic nervous system • A decrease in blood pressure and pulse rate • Decreased muscular activity.

Relaxation is both mental and physical: • Anxiety, overwork, noise and other disturbances will interfere with mental relaxation. • Pain, discomfort, tension and hunger will interfere with physical relaxation.

Bedrest Bedrest, or confinement to bed, is, in some instances, a form of therapy and therefore prescribed to reduce strain and enhance recovery. This may be complete bedrest, or modified to allow the use of the toilet only, depending on the severity of the condition. The conditions include the following: • Congestive cardiac failure • Myocardial infarction • Severe respiratory disease with marked dyspnoea • Cerebral aneurysm • Some cases of hypertension • Muscle and/or bone injury, for example fractures of the pelvis and femur.

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In other instances, bedrest is mandatory as dictated by the condition, such as in paralysis and unconsciousness. Most doctors, however, will allow even patients on strict bedrest to get out of bed to use a bedside commode to urinate. This is because trying to get a patient to pass urine in a recumbent position involves more strain than assisting the patient to stand at or sit on a bedside commode.

Positions in bed The position of the patient in bed depends on several considerations: • The maintenance of comfort and good body alignment • The presence or absence of factors such as hyper/hypotension, cardiac problems, respiratory distress and dyspnoea, head injuries, or raised intracranial pressure, unconsciousness • The presence of injuries or surgical incisions • The presence of IV lines, arterial lines, urinary catheters in situ, ventilator tubing and surgical drainage tubes/bottles. Table 22.1  Positions in bed Position

Description

Indication and rationale

Fowler’s

Patient is semi-sitting with the head and trunk raised • Semi-Fowler’s or low Fowler’s: the head and trunk are raised 15–45º • High Fowler’s: the head and trunk are raised 45–90º • The orthopnoea position is a variation of high Fowler’s in which the patient sits upright and slightly forward, with the head resting on pillows placed on a cardiac table. Can also be done with the patient in a chair at the side of the bed and resting the head on the bed itself

• Comfort/preference • Respiratory conditions such as respiratory distress • Cardiac conditions such as myocardial infarction. The semi-Fowler’s position is a position in which optimum cardiac rest combined with optimum venous return is facilitated to facilitate an improvement in cardiac output. This position is thus ideal for patients with cardiac conditions • Respiratory distress and dyspnoea • The orthopnoea position is used for patients with severe dyspnoea that is not improved in the high Fowler’s position • To relieve tension on an abdominal wound

Dorsal recumbent or supine

The patient lies flat on the back. The head may be supported with one or two pillows, and pillows may also be placed under the heels and elbows to provide support and relieve pressure

• Comfort/preference • Patients who are hypotensive should lie supine to maximise venous return and cardiac output • Patients who are in traction for problems of the neck and back  ➙

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Position

Description

Indication and rationale

A flat soft pillow may be placed in the small of the back to provide support

• During a bed bath • After lumbar puncture procedure • For patients with neck or spinal injuries

Prone

The patient lies on the abdomen, with the head to one side. Pillows are placed under the abdomen and the lower legs to provide support. The head should be supported with a soft flat pillow to maintain good alignment of the neck

• Comfort/preference • To facilitate the drainage and removal of secretions from the bases of the lungs • To facilitate ventilation and expansion of the bases of the lungs

Lateral

The patient lies on one side. A pillow is used to support the head, and a firm pillow may be placed against the back to support the patient in the lateral position. A soft pillow can be placed between the knees to relieve pressure there

• Comfort/preference • This position is often used as an alternative to the dorsal position for patients who have to lie flat

Semi-prone or Sim’s position

The position of the patient is between the lateral and the prone position. The patient lies on one side with the legs flexed, the upper leg being flexed more acutely at both hips and knee so that it lies in front of the lower leg. The lower arm is placed behind the patient and the upper arm is placed in front of the head. The head may be supported on a soft flat pillow turned to one side, and pillows are placed under the knee of the upper leg and under the upper arm for support

• Comfort/preference • May be used for unconscious patients as drainage from the mouth and maintenance of the airway is facilitated • Used for patients who are recovering after general anaesthesia • Used to administer enemas and for procedures involving the anal and/or perineal area, for example insertion of suppository • Used after tonsillectomy to allow the drainage of blood and secretions from the mouth

Trendelenburg

Patient lies on the back or stomach with the foot end of the bed elevated on bed blocks

• To treat shock • To treat oedema of the lower limbs • Sometimes used in cases of hypotension

Knee–chest

Patient kneels and puts the chest and head on the bed

• Used for the examination of the rectum and sigmoidoscopy ➙

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Position

Description

Indication and rationale

Lithotomy

Patient lies on the back with the legs lifted at a 90° angle at the hip with the knees bent at the same angle. The feet may be supported in stirrups

• Rectal examination and operation • Vaginal examination • During delivery

A. Semi-Fowler’s position

B. Fowler’s position

C. Dorsal position (recumbent or supine position) ➙

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D. Prone position

E. Lateral position

F. Semi-prone position (Sim’s position)

Figure 22.2  Positions in bed

Guidelines for positioning of a patient • The position should be appropriate for the patient’s physical condition, specific medical/surgical or nursing problem or preference if not contraindicated. For example, it is not appropriate to place a patient suffering from shock in high Fowler’s position. • The position should be comfortable, and relieve the patient of symptoms. • The limbs should be placed in a natural and functional position. • Circulation should not be impeded in any way. • The limbs and body should be supported as and where appropriate. • The patient should not have to exert any effort in order to maintain the position. • The patient’s position should be changed or varied at regular intervals with ease.

Common clinical problems related to maintenance of mobility Complications of bedrest 1. Respiratory system. As a complication of bedrest, oxygen requirements are reduced and breathing is shallower. The alveoli in certain areas of the lungs, usually the 466

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bases, are not adequately expanded because of the recumbent position and thus collapse, a condition known as atelectasis. Furthermore, the patient usually presents with a weak cough reflex. The above scenario allows secretions to accumulate and stagnate, resulting in hypostatic pneumonia. In the elderly, immunosuppressed or debilitated patients, hypostatic pneumonia is a serious complication that may lead to death. Other complications of pneumonia such as pleurisy, and lung and pleural abscesses may occur and further retard the patient’s recovery. 2. Cardiovascular system. Stasis in the circulation due to immobility, particularly in the legs and pelvic area, increases the coagulability of the blood, leading to the development of deep vein thrombosis in the leg or pelvic veins. The formation of a blood clot further impairs the venous return from these areas and, especially in the legs, the parts distal to the clot become oedematous and painful. The vessel wall surrounding the clot may become inflamed, a condition known as thrombophlebitis. Clots lodging in lungs cause pulmonary embolism, a serious problem which may be fatal. Patients most at risk of thrombophlebitis are those who: • are immobile, as already stated • have recently undergone surgery, especially orthopaedic, abdominal or cardiac surgery • are pregnant or who have recently given birth (are post-partum) • suffer from a cardiac condition • are obese • have suffered trauma, especially major trauma or multiple trauma, and are confined to bed • have a history of a previous deep vein thrombosis • are over 50 years of age • are on oestrogen therapy, and some forms of oral contraceptives.

Pulmonary embolism This is a serious complication and is a medical emergency. The most common precipitating cause of pulmonary embolism is deep vein thrombosis. A blood clot in the veins of the legs or pelvis may dislodge, often following a sudden movement, and travel in the circulation through the heart into the lungs. Once it gets lodged in the capillary bed or artery in the lungs, it will cut off the blood flow to the areas of lung supplied by that artery, and decrease oxygenation. The precise effects of the embolism depend on the size of the clot and the area of the lung that is affected: • A large clot lodging in a large branch of the pulmonary artery will cause cardiovascular collapse, acute right-sided cardiac failure, acute respiratory failure and probably death. • A smaller clot may still cause significant cardiac and respiratory problems but will not necessarily lead to death. • A very small clot may produce no symptoms whatsoever. • The clinical manifestations of pulmonary embolism include the following: –– The sudden onset of pleuritic chest pain. This is sharp and stabbing in character and is related to breathing, being worse on expiration. ➙

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–– –– –– –– ––

Dyspnoea, which may or may not be accompanied by cyanosis. Cough, which is often associated with haemoptysis. The patient is extremely anxious and restless. Syncope may occur. The patient may exhibit the symptoms of circulatory shock due to the sudden drop in cardiac output and the hypoxia thereof. –– Mild pyrexia develops shortly after the event.

Management of pulmonary embolism This is an emergency SUMMON THE DOCTOR URGENTLY!!! • Administer oxygen and sit the patient up unless the patient is shocked and hypotensive, in which case the patient should lie flat. • Keep the patient in bed and minimise straining, in order to minimise cardiac work.

Nursing alert! The patient with pulmonary embolism may experience the urge to micturate or defecate due to the sudden drop in cardiac output and blood pressure. Putting the patient on a bedpan or, even worse, getting the patient out of bed to urinate, is the last thing the nurse should do in these circumstances. A careful assessment of the patient and experience will tell the nurse whether this is a normal toilet request or whether the patient is suffering from cardiovascular collapse.

• The vital signs should be monitored at frequent intervals (every 15–30 minutes) until the patient is stable. • Medical management usually includes the following: –– Intravenous fluids are given to maintain the circulation and the cardiac output. –– Intravenous anti-coagulants are given during the acute phase of illness, followed by oral warfarin once the patient has improved from the acute phase. NB! Patients on warfarin need a regular blood-clotting international normalised ratio (INR) test to titrate the warfarin dosage. –– Inotropic agents may be used for patients who are severely shocked. –– Mechanical ventilation is sometimes necessary.

3. Integumentary system. Prolonged pressure on the soft tissues, and especially the skin, causes capillary compression and subsequent occlusion of blood flow to the area. If the pressure is not relieved at this stage, micro-thrombi develop within the capillaries, which totally occlude blood flow. This leads to tissue necrosis, skin breakdown and ulceration of the underlying soft tissue. Once the underlying tissue has started to break down, the sore, known as a ‘decubitus sore’, ‘bedsore’ or ‘pressure sore’, may develop and become deeper and deeper until even bone 468

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and cartilage are exposed. This may become infected and further eroded. Chronic bedsores that fail to heal may ultimately become cancerous.

Sites for pressure sores Hips, sacrum, elbows, heels, ankles, ears



Specific risk factors for the development of pressure sores include the following: • Immobility. This may be due to bedrest or confinement to a bed, chair or wheelchair, such as in paralysis and/or unconsciousness. • Moist skin. Moisture softens the skin and encourages skin breakdown. This is a factor in patients who are incontinent of urine or faeces, or who sweat profusely and are confined to bed. • Poor nutrition. This results in poor healing, and increased friability and drying of the skin. Fragile, dry skin is more liable to break down. • Sensory loss. Loss of sensation as in paralysis means that such patients are unable to perceive the discomfort caused by the pressure on their skin and will not feel the urge to change position or move, or ask for their position to be changed. • Friction and shearing forces. These occur in patients who are at bed or chair rest. A force is exerted on the skin from the underlying tissues with pressure and movement. This shearing force may cause small breaks in the skin, which then develop into bedsores with continued pressure. • Old age. The skin loses its ability to maintain normal integrity with advancing age. In the elderly, the skin becomes thinner and more fragile, and thus more prone to breakdown. • Other conditions, such as poor circulation, diabetes mellitus, impaired mental functioning, anaemia or pyrexia may also make the skin more prone to breakdown. • The very obese and/or the very thin are more at risk than individuals of normal weight. 4. Musculoskeletal system. Prolonged bedrest and immobility may result in deformities and contractures. • Joint stiffness due to bedrest reduces mobility at the joints, and the tendons around the immobile joint or joints may, over time, become permanently lengthened or shortened. Once this has happened, the resulting deformity can usually only be corrected by surgery. These deformities, which are usually in a position of flexion, may occur in any joint that is immobile for a prolonged period. Joint deformities interfere with movement and with the normal function of the joint. An untreated joint contracture may be crippling, which makes it very important for the nurse to prevent these deformities from developing. • Demineralisation of bone during bedrest leads to loss of bone mass, a condition known as ‘disuse osteoporosis’. • Severe loss of muscle strength and bulk is also a result of bedrest. The unused muscles lose mass and become wasted.

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Heels

Malleolus

Toes

Sacrum

Knee (medial and lateral condyles)

Knees (patellas)

Greater trochanter

Elbows

Ischium

Genitals (men)

Scapulae

Shoulder (acromial process)

Breasts (women)

Back of head

Ear

Acromial process

Side of head

Cheek and ear

Figure 22.3  Diagram showing pressure areas of the body 5. Genito-urinary system • Demineralisation of bone during bedrest releases calcium salts into the circulation, which are then excreted by the kidneys. Large quantities of calcium salts passing through the kidneys may result in the formation of kidney stones or renal calculi. • Inactivity also leads to urinary retention and stasis, with the awkwardness of using a bedpan or bottle as a contributing factor. This stagnant urine is a good culture medium and easily becomes infected. The development of urinary tract infection may lead to death due to renal failure, or to permanent renal impairment. If the bedridden patient is catheterised, the likelihood of urinary tract infection is even higher. After pneumonia, renal failure from repeated urinary tract infections is the leading cause of death in patients who are immobile or bedridden for long periods of time.

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6. Gastrointestinal tract system • Immobility reduces the activity of the gastrointestinal tract, leading to constipation, which is a very common complication of bedrest. The decrease in bowel motility results in more water reabsorption from the bowel, decreasing the amount of water in the faeces and making them hard and small. • Bedrest may result in a lack of appetite due to decreased basal metabolic rate (energy requirements are diminished). This may result in the patient taking in insufficient nutrients and fluids for recovery. An inadequate food intake may exacerbate muscle wasting and may predispose the patient to infection that he or she can ill afford. 7. Psychological issues Bedrest and enforced inactivity can result in boredom and depression. The patient may become anxious about family wellbeing if she or he is the breadwinner and the period of bedrest is to be of long duration. This anxiety may occur even if the patient is not the breadwinner, but as a result of isolation from the family and community experienced while the patient is in hospital. The patient may also be worried about job security and the financial implications of hospitalisation. The resulting stress and anxiety may lead to a feeling of decreased self-esteem. In addition, being confined to bed is very monotonous, particularly if the patient has been accustomed to a busy lifestyle with many activities. The bored patient thus has very little to do except watch the activities of the nursing staff and the other patients and brood on his or her problems. A further problem, particularly if the period of bedrest is prolonged, is overdependence on the staff. The patient may seem to be very demanding and unable to do anything for her- or /himself. In fact, the patient may feel apprehensive and anxious about resuming independent activities after a long period in bed.

Prevention and management of the complications of bedrest 1. Respiratory system • Identify those patients who are most likely to develop pulmonary complications: –– Elderly or debilitated patients –– Patients with infections of the upper respiratory tract –– Patients who may have inhaled vomitus –– Heavy smokers –– Patients with chronic lung conditions –– Obese patients. • Promote full expansion of the lungs: –– The patient’s position should be changed regularly in order to expand different parts of the lungs. –– Encourage deep breathing at regular intervals. –– Encourage and assist the patient to cough up secretions. –– The patient can be referred for preventative physiotherapy. • The nurse should be alert for any signs of pulmonary complications: –– A rise in temperature –– An increase in pulse and respiration 471

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–– Restlessness, anxiety and confusion, particularly in the elderly –– Dyspnoea, cough and/or chest pain. • Management involves the following: –– Treatment of infection with an appropriate antibiotic, as prescribed by the doctor –– Intensive chest physiotherapy to promote lung expansion and the removal of secretions –– Oxygen therapy as prescribed to ensure adequate oxygenation. Progress is monitored by means of vital signs and periodic chest X-rays, which should show an improvement. 2. Cardiovascular system • Prevention of clot formation: –– The nurse should carry out passive leg exercises at regular intervals; where possible, patients should be encouraged to do this for themselves. –– Elastic anti-embolism stockings may be applied; pressure thus applied at the surface helps to move the blood back to the heart. –– Low doses of an anticoagulant such as Clexane may be prescribed; this reduces the coagulability of the blood and reduces the chances of clot formation. –– Prevent dehydration. –– Take care not to place pillows or support devices under the popliteal fossa as these may occlude venous return and predispose the patient to venous stasis and subsequent clot formation. –– Early ambulation and mobilisation are highly recommended. • Early detection and reporting of any sign of circulatory complications: –– A deep vein thrombosis should be suspected if the patient presents with a painful, oedematous ankle and calf, which may be accompanied by a slight rise in temperature. –– A positive Homans’ sign, in which flexion of the ankle causes a sharp pain in the calf, is also suggestive of a deep vein thrombosis.

Figure 22.4  Homans’ sign –– The sudden onset of dyspnoea, together with a sharp, knife-like, stabbing or poking chest pain, should make the nurse suspect a pulmonary embolism. A large pulmonary embolism, however, may present with cardiovascular collapse and constitutes a medical emergency (see management of pulmonary

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embolism on page 468). The diagnosis of pulmonary embolism may be confirmed by means of an electrocardiogram and a chest X-ray. • Circulatory complications of bedrest are managed as follows: –– Anticoagulant therapy is commenced as prescribed by the doctor. This consists firstly of heparin, which is given intravenously. After a few days the patient may be changed to Clexane or to oral warfarin. –– The patient is kept in bed until the clot has resolved. –– The painful area must not be massaged as this may dislodge the clot and cause an embolus. –– Anti-embolism stockings or elastic bandages are applied. –– If thrombophlebitis is present, anti-inflammatory and anti-phlebitic ointments such as Reparil gel can be applied as prescribed. Old-fashioned hot poultices are very good at reducing the pain of thrombophlebitis, but these have fallen into disuse and are seldom used nowadays. –– The weight of the bedclothes should be kept off the affected limb by means of a bed cradle. This reduces pain in the limb and promotes comfort. –– Elevation of the foot end of the bed assists with venous return and prevents venous stasis. –– For patients who repeatedly develop deep vein thromboses, surgical procedures such as the insertion of an umbrella filter in the inferior vena cava may be carried out to prevent the migration of clots to the heart and the lungs. 3. Integumentary system • Identify the patients most at risk: –– The obese and the emaciated –– Patients with poor circulation –– Patients with fragile, dry skin –– Restless, unconscious or paralysed patients –– Patients with lowered resistance, namely very ill patients, malnourished patients, oedematous patients, anaemic patients, patients with malignant disease, patients with diabetes mellitus and patients taking systemic corticosteroids –– Patients with a lowered immune system such as those who are very ill, malnourished, oedematous, anaemic or diabetic; those with malignant diseases; and those taking systemic corticosteroids.

Patients need to be assessed in relation to their risk for the development of pressure ulcers. Various scoring systems have been developed to assist in this assessment, which should be carried out on all patients on admission, and at least every third day on long-term patients. High-risk patients should be assessed on a daily basis. The Norton scale is one such system, which provides a useful tool for assessing the risk of the development of pressure sores.

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Table 22.2  The Norton scale Physical

Mental state

Activity

Mobility

Incontinence

condition

Good

4

Alert

4

Ambulant

4

Full

4

Not

4

Fair

3

Apathetic

3

Walks with help

3

Slightly limited

3

Occasional

3

Poor

2

Confused

2

Confined to chair

2

Very limited

2

Usually of urine

2

Bad

1

Stuporous or unconscious

1

Confined to bed

1

Immobile

1

Incontinent of urine and faeces

1

The lower the score, the higher the risk.

• Relieve pressure over pressure points: –– By regular turning and position changes – the frequency depends on the risk as assessed above, but is usually done 2–4 hourly –– By the use of appliances, such as bed accessories and/or special beds and mattresses to relieve pressure; a monkey chain is particularly useful in aiding patients who are able to relieve pressure without nursing intervention. • Maintain the condition and integrity of the skin: –– By promoting adequate circulation by changing position every two hours –– By protecting the skin from injury, especially by long nails and jewellery of staff –– By taking appropriate measures for skin that is over-dry –– By preventing friction and shearing, especially when moving a patient in bed: take care not to drag the patient up the bed but lift; ensure that there are sufficient staff to assist to prevent shearing force and injury to the nurse and patient –– By preventing friction from foreign objects in the bed such as crumbs and creased linen –– By keeping the patient clean and dry, and if incontinent washing with mild soap and ensuring that the skin is kept dry. • Maintain and improve resistance by ensuring a nourishing well-balanced diet and adequate fluid intake. • Report and record any redness of skin over prominent areas in a patient who is confined to a bed or wheelchair.

Clinical alert! NB! Do not rub prominent sites with lotions or alcohol-based preparations as these will cause further damage.

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4. Musculoskeletal system • Place limbs in a natural and functional position: –– A position of slight flexion is recommended. –– The hand should always be positioned in the grip position. –– The ankle should be flexed in a standing position. –– The hands and the feet may require splinting to keep them in the functional position. –– The limbs should be adequately supported using pillows. • Range of motion exercises should be carried out on all joints at regular intervals, unless contraindicated by injury. Any stiffness or tendency of a joint to remain in one position should be reported. • Once contractures have occurred, long-term physiotherapy will be required to restore some degree of function at the affected joint. If this is unsuccessful, surgery is required to lengthen the tendons and adjacent soft tissue, and restore a degree of function. Neither of these options has a particularly high success rate, and the patient is often left with a residual permanent deformity. • Drop foot is a type of joint contracture in which the patient is unable to dorsiflex the foot – that is, the foot is contracted in the position of plantar flexion. This is caused by the shortening of the Achilles tendon due to poor positioning of the foot or possibly due to the weight of the bedclothes continually pressing the foot into a position of plantar flexion. –– As with the other types of contracture, exercise of the ankle joint is vital. –– The nurse should also check the position of the foot and use a bolster, board or some other device to keep it in a neutral position. –– The bedclothes should not be tightly tucked in over the foot, and a bed cradle may be useful to relieve pressure on the foot. –– A special orthosis or splint may be made to maintain the correct position of the foot. • Dropped hand is a type of contracture in which the hand is contracted in a position of flexion. The primary cause seems to be poor positioning of the hand in bed, particularly in the case of unconscious patients and those with decorticate or decerebrate postures in cases of brain damage. Although the patient can still grip, the hand cannot be extended and this limits the function of the hand. –– Exercise of the wrist joint is essential. –– Exercises should include not only range-of-motion exercises but exercises that strengthen the grip and the flexibility at the wrist. –– A splint is usually needed to keep the hand in the functional position. • It is not possible to prevent osteoporosis in a patient who is at bedrest for a prolonged period of time. Early ambulation is essential to prevent severe osteoporosis, and most patients will regain normal bone mass within a few weeks of commencing active mobilisation. On discharge, the patient must be educated to exercise actively and to take care not to fall, as such patients are more prone to fractures until normal bone mass has been regained. Some authorities advocate the use of calcium supplements and increased dietary calcium for patients at bedrest. However, there is no proof that this has any significant effect on the 475

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bone loss, and the increased calcium intake could increase the risk of renal calculi. • Muscle weakness and muscle wasting can be alleviated by active/passive exercises to a limited extent. The nurse should take care when the patient first starts to ambulate, as the muscle weakness makes the patient much more liable to fall until normal muscle strength is regained. 5. Genito-urinary system • An adequate fluid intake of about 2 000–2 500 ml in 24 hours for an adult should be promoted in order to prevent urinary stasis. Adequate fluids will also help to prevent renal calculi by flushing the kidneys. • Intake and output should be monitored. • Regular urination should be encouraged 3–4 hourly. The nurse should provide privacy for the patient. As far as possible, the patient should be assisted to assume the normal position for passing urine. • The treatment of urinary tract infection consists of a suitable antibiotic as prescribed by the doctor. Adequate fluids will help to flush the bladder and remove infected urine. 6. Gastrointestinal tract system • The nurse must ensure that the patient has an adequate fluid intake. • The amount of fibre in the patient’s diet should be increased. Fibre provides bulk and helps to retain water in the large bowel, thereby maintaining the normal consistency of the faeces. • Regular bowel movements should be encouraged as this prevents stasis of faecal matter. This is not always easy, as many patients are embarrassed to use a bedpan or commode in the ward. The nurse should provide as much privacy as possible. • The above measure can also be used to manage constipation. The doctor may prescribe a mild laxative while the patient is immobile, but this should be discontinued as soon as possible. • If constipation is allowed to become prolonged, faecal impaction results. The faecal matter becomes impacted within the bowel, necessitating manual removal, a painful and unpleasant procedure for both patient and nurse. • Adequate nutrition should be actively promoted. A diet that is high in proteins and vitamins should be encouraged. Attractive meals and attention to the patient’s likes and dislikes may stimulate appetite. 7. Psychological issues • Try to interest the patient in his or her surroundings. • Books, magazines and newspapers may help if the patient can read. • Place the patient in a bed with a view, or with other patients who will provide pleasant and congenial company. • A radio or television can be provided for patients who do not feel like reading, or who cannot read. • If the patient is interested, the occupational therapist will organise handwork for the patient. • A referral to the social worker may be necessary to solve family or financerelated problems that are causing anxiety. 476

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Moving patients Patients who have decreased mobility may need assistance in moving in bed. The nurse must take care to move such patients correctly to minimise injury to them or to him- or herself.

Guidelines for moving patients • Place the bed in as flat a position as possible for the condition of the patient. • Remove as many pillows as possible. • Assess the patient’s level of mobility, size and weight. • Assess the amount of strength required to move the patient to decide if assistance is needed. • Plan and utilise any assistive devices that may be required. • Assess the need for analgesia before moving the patient if the patient is in pain. • Explain the procedure to the patient as well as ways in which the patient can assist, if appropriate. • Raise the height of the bed for your comfort and safety. This makes it easier to move the patient correctly. • Ensure that the wheels on the bed are locked for the safety of the patient. • If moving the patient on your own, consider putting up the side rail (cot side) on the side opposite to you to ensure patient safety. • Ask the patient to flex both knees and place feet flat on the bed to assist in pushing up in the bed. • If a monkey chain is available, ask the patient to hold it with both hands and assist in lifting with the chain. • Otherwise, ask the patient to fold the arms over the chest, flex the neck and keep head off the surface of the bed. • Place one arm under the patient’s thighs, the other under the shoulders and assist the patient to lift the buttocks off the bed and push up towards the head of the bed using the feet. Ensure that the buttocks are lifted off the bed to prevent a shearing force on the skin. • If the patient is unable to assist in moving, two nurses are required to do so. Turning a patient in bed • Move the patient closer to the side opposite to the one which he or she will be facing when turned. • Put up the side rail to prevent the patient from falling. • Go to the opposite side of the bed, place one hand on the patient’s shoulder, the other on the patient’s hip, and pull the patient towards you. • Position the patient in a lateral position, supporting the back and arms with pillows where necessary. Place a pillow between the patient’s legs to prevent pressure on the knees and ankles. • A pull sheet may be used to assist if the patient is immobile. Logrolling a patient • This technique is used to move a patient whose body needs to be kept in a straight alignment. The patient is turned as if rolling a log. 477

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• It is used particularly on patients with spinal injuries or following spinal surgery. • At least two nurses are required for this procedure; three if the cervical spine is the affected area. • All nurses stand on the same side of the bed. • One nurse places one hand on the shoulder of the patient and the other on the buttocks. • The second nurse places one hand in the waist area and the other behind the knee. • The first nurse co-ordinates the roll – counting to three, the patient is rolled towards the nurses on the count of three. • The side rail is put up, and the nurses move to the other side of the bed to pull the patient to the centre of the bed. • A pillow is placed behind the patient’s back, one under the head to maintain alignment of the neck and one between the legs. • If the patient has a cervical spine injury, the third nurse stands at the head of the bed (behind the bed) and maintains alignment of the head and neck by supporting the head on either side. This nurse must co-ordinate the roll.

NB! Patients with spinal injuries are nursed on a spinal bed, which has special gadgets that make turning such patients easy and safe.

Role of the physiotherapist and the nurse The physiotherapist plays a vital role in the mobility and rehabilitation of the patient. The physiotherapist will assess the patient’s mobility and prescribe an exercise regime for the patient. The patient at bedrest will receive chest physiotherapy to prevent hypostatic pneumonia and atelectasis. The nurse may continue to assist the patient with chest and breathing exercises in the absence of the physiotherapist. Passive or active exercise regimes will be commenced by the physiotherapist and continued by the nurse. On mobilising a patient, especially where assistive devices such as crutches or walking frames are used, the physiotherapist will initially educate the patient on the use of these. Thereafter the nurse can assist the patient until full mobility is gained. This role forms part of the interdependent function of a nurse (working in collaboration with other members of the health team).

Conclusion This chapter discussed a significant self-care modality, that of mobility. It is in mobility that people are able to fulfil activities of daily living which are all so important. Mobility determines our ability to function, our visibility in society and communities alike, and therefore our health status. Immobility not only has a negative effect on all the systems of the body, it impacts on motivation and the will to live as it reduces selfsufficiency and self-determination, often causing depression, which is a very difficult chronic condition to manage.

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Suggested activities for students Activity 22.1 Bedrest, although therapeutic, can lead to complications that affect the systems of the body in different ways and extent. Preventing these complications is an independent nursing function that forms the basis of basic nursing care. Development of pressure sores is an indictment on the nursing in a health facility, hence if reported the nurses concerned are brought before the Nursing Council for disciplinary action. First-year nurses are required to each write and present a case study of a patient confined in bed (not unconscious). In the case study: a. Present the history that has resulted in the patient being confined to bed. b. Describe the patient’s actual and possible problems as a result of confinement to bed. c. Outline the prevention of potential problems and the management of actual problems identified and experienced. In the presentation, ensure that ethical and medico-legal aspects are highlighted.

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chapter

23

Elimination needs

Learning objectives On completion of this chapter, the student should be able to do the following: • Understand the importance of the elimination process. • Conduct an assessment and interpret assessment findings relating to elimination. • Make accurate observations, measurement and recording of urine, stool and vomitus. • Collect urine and stool specimens for ward and laboratory examination and tests. • List common ailments related to elimination. • Demonstrate the ability to develop effective care plans for patients with altered elimination patterns. • Demonstrate the ability to provide basic nursing care for patients with altered elimination patterns.

Key concepts and terminology Albuminuria: Presence of albumin or globulin in the urine. Anuria: Absence of urine, or urine output of less than 50 ml/day. Choluria: Bile in the urine. Chyme: Digested food mixed with gastric juices and enzymes in the small intestines ready for absorption into the circulatory system. Constipation: Difficulty in passing a stool, which is usually hard. Defecation: The act of expelling faeces through the anus in response to an urge. Diarrhoea: A loose stool that is passed frequently and if not well managed could lead to dehydration. Dysuria: Pain and difficulty in passing urine. Elimination: The removal of waste products from the body. Emesis: The act of vomiting. Frequency: Micturition more often than the patient’s expectation. Glycosuria: Presence of sugar in the urine as a result of hyperglycaemia. Haematuria: Blood in the urine.

➙

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Homeostasis: The term used to describe regulatory mechanisms that maintain a balance in electrolytes and water in the extracellular and intracellular compartments in the body. Hyperglycaemia: Abnormally high levels of sugar in the blood. Incontinence: Inability to control urine or stool. Ketonuria: Ketone bodies in the urine. Melaena: Blood in the stool, characterised by a black tarry stool. Micturition: The act of passing urine (the same as ‘urinating’). Oliguria: A decreased urinary output of below 300–500 ml/day. Peristalsis: Contractions in a lumen in an effort to propel the contents of the lumen forward. Polyuria: An increased urinary output of more than 3 000 ml/day – the specific gravity (SG) is low, < 1005. Proteinuria: Presence of detectable proteins in urine. Pyuria: Pus in the urine. Specific gravity (SG): The degree of dilution of urine as measured with a urinometer. Steatorrhoea: Pale, fatty and frothy stool. Urobilinogen: Altered bile pigment absorbed from the gut and excreted via the kidneys in the urine. Urinometer: An instrument used to measure the specific gravity of urine. Vomitus: Ejected contents of the stomach.

Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy and physiology of the genito-urinary system and that of the gastrointestinal tract system • Biophysics and biochemistry • Physical assessment of the patient.

Medico-legal considerations The scope of practice of registered nurses authorises them to carry out the following interventions related to the maintenance of elimination with care: • Assessment of elimination needs and the identification of problems related to elimination, such as constipation, faecal impaction and retention of urine • Accurate recording of intake and output • Measures to maintain optimum urine output and renal function • Use of incontinence aids

➙

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• Application of condom drainage/Paul’s tubing • Catheterisation of the urinary bladder • Management of drainage systems • Management of bladder irrigation and instillation • Catheter care.

Key ethical considerations • Patients must always be treated with dignity and respect. Always ensure privacy when carrying out procedures relating to elimination. Nurses should not expose a patient unnecessarily, nor should they act or speak in a coarse manner when dealing with the function of elimination. • The comfort and cleanliness of incontinent patients must be maintained at all times. To clean a patient who is incontinent and make that patient comfortable is one of the basic nursing actions, and nurses can take pride in carrying out this task diligently and with care. Above all, do not abuse an incontinent patient: such patients cannot help themselves, and they certainly do not wet or dirty themselves on purpose.

Essential health literacy • Patients and the general public alike need to be made aware of the dangers inherent in the overuse and abuse of laxatives. • Education regarding the prevention of constipation through diet, sufficient fluids and regular exercise is important and will help to prevent or reduce laxative abuse. • Education of the community in relation to the management of diarrhoea in children and adults is mandatory as this is a killer if not appropriately managed. • In general, people must respond to the urge to urinate or defecate when it presents.

Nursing implications • Failure to obtain, test and/or send ordered specimens to the laboratory may lead to a prolonged stay in hospital for the patient. • Failure to note and record any abnormalities of urine and/or faeces, problems with micturition or defecation, or vomiting may lead to a wrong diagnosis. Any of these problems may be due to an underlying problem or may indicate a change in a patient’s condition. • When catheterising a patient, carrying out bowel washouts or obtaining specimens, the following should be noted: –– Consent should be obtained and an explanation of the procedure given. –– Infection control measures must be complied with, especially during catheterisation. –– In the case of catheterisation and catheter care, the nurse must ensure that all necessary precautions are taken to avoid injury. ➙

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–– When catheterising a patient, never force the catheter if an obstruction is encountered, especially in the case of middle-aged and elderly men in whom the prostate gland may be enlarged.

Introduction In this chapter, nurses will be introduced to the important bodily function of elimination, which is the means whereby wastes and toxins are excreted from the body. Nurses will be assisted to develop an understanding of the regulation and control of bladder and bowel function, including reflex actions such as vomiting. They will be encouraged to become proficient in the assessment of bowel and bladder function, and be assisted to develop competence in the prevention and management of common problems associated with elimination, such as dysuria and constipation. Nurses will thus be in a position to develop effective care plans for patients with altered elimination patterns, including the evaluation of care and the monitoring of patients’ progress.

Normal physiological function of elimination The human body must rid itself of waste products to maintain effective functioning. Four mechanisms exist in the body to make this possible: • The formation of urine by the kidneys and the excretion of urine via the urinary tract • The expulsion of faeces (defecation) from the gastrointestinal tract (GIT) after digestion and absorption have been completed • The excretion of some waste products in the form of sweat from the skin • The removal of carbon dioxide and water via the lungs during expiration. Interference with normal elimination will certainly become a stressor for many patients already suffering from stress. A nurse’s understanding of the normal elimination process can be very important when assisting a patient to adapt to the hospital environment.

Urine Urine is the end product of the urinary system. Figure 23.1 outlines the structure of the urinary system. It consists of two kidneys, two ureters, the bladder and the urethra. The main functions of the kidneys are as follows: • Waste disposal. The kidneys filter all the waste products of metabolism from the blood. Excess water, solutes such as sodium chloride, metabolic by-products

Kidney

Ureter

Bladder Urethra

Ureter opening

Figure 23.1  The urinary system

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such as urea, and ingested toxic substances are removed from the body in the process of urine formation. • Homeostasis. Homeostasis is the term used to describe regulatory mechanisms that maintain a balance in electrolytes and water in the extracellular and intracellular compartments in the body. The intricate structure and functioning of the kidney maintain the constant composition and volume of the blood so as to ensure homeostasis in the intracellular and extracellular compartments of the body. The mechanism includes urine formation, regulation of osmotic pressure and acid–base balance. • Urine formation. The kidney produces urine. Each kidney has an artery that originates in the aorta and enters the kidney at the hilum. The renal vein extends from the hilum to join the inferior vena cava. It is estimated that 1 200 ml of blood passes through the kidneys every minute in the average adult (±21% of cardiac output). Bowman’s capsule

Glomerulus

Proximal tubule

Arteriole from renal artery Arteriole from glomerulus

Distal tubule Branch of renal vein

From another nephron Collecting duct

Loop of Henie with capillary network

Figure 23.2  The nephron and urine formation From this circulating blood, the glomeruli in the nephrons (the functional unit of the kidney) effectively filter off excess water and wastes forming a fluid called glomerular filtrate (±120 ml/minute). The glomerulus is a tuft or cluster of blood vessels that are surrounded by the Bowman’s capsule. The capsule has pores large enough to let water and some small particles of solutes pass through. The pores do not allow large protein molecules to filter through, which means that the blood retains the essential elements needed by the body through selective reabsorption. The glomerular filtrate is chemically almost the same as plasma but only has very small quantities of protein, and consists of water, electrolytes, creatinine, urea, amino acids, glucose, uric acid, bicarbonate and other electrolytes. These products pass along the nephron’s tubules 484

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where about 99% of water and essential solutes are reabsorbed into the bloodstream. The tubules also secrete substances such as drugs into the urine. The 1% that is left forms the urine to be excreted. The anti-diuretic hormone (ADH) regulates the amount of water reabsorbed by the renal tubules in response to fluctuations in the osmotic pressure. Aldosterone stimulates the renal tubules to reabsorb sodium and excrete potassium. Retention of sodium results in an increase in the osmotic pressure followed by the release of ADH and a decrease in water loss. Increased water loss is caused by the reversal of the process. Once the urine has been formed in the kidneys, it enters the ureters via the collecting ducts in the kidney and then passes on to the bladder. The cystic bladder is a hollow, muscular organ that serves as a reservoir for urine. It has considerable elasticity and is capable of great distension. The bladder is emptied by contraction of its muscles. The desire to urinate is caused by sensory stimulation in the bladder as a result of the pressure of urine on the wall of the bladder, the chemical composition of urine and the reflex stimulation. Micturition

When 300–500 ml of urine is contained in the bladder, nerve endings in the detrusor muscle receive stimuli that are transmitted to reflex centres in the spinal cord. The internal sphincter (just above the point of insertion of the urethra into the bladder) is opened, allowing urine to enter the urethra. The external sphincter then relaxes, allowing the expulsion of the contents of the bladder. After three years of age, the external sphincter is normally under voluntary control and micturition can therefore be delayed by contraction of this sphincter. Delaying micturition can only postpone the passing of urine temporarily; after a while the urge will become irresistible, and the individual may experience incontinence if he or she delays for too long. When the bladder becomes distended to 1 000 ml or more, bladder tone may be lost and tissue damage can occur.

Faeces Gastrointestinal tract and formation of faeces

The gastrointestinal tract (GIT) is a hollow muscular tube that extends from the mouth to the anus and has as its principal function the provision of the body with fluids, nutrients and electrolytes. A secondary function of the tract is to dispose of the waste residue from the digestive process. Only undigested waste products from the tract are eliminated as other routes such as the lungs, kidneys and skin excrete wastes from body metabolism. Elimination of the waste products of digestion from the body is essential to health. The excreted waste products from the GIT are referred to as faeces or stools. The elimination function of the GIT is mainly from the colon (large intestine) which extends from the ileo-caecal valve (between the small and large intestine) to the anus – generally 125–150 cm long in the adult. It consists of the caecum; ascending, transverse and descending colon; sigmoid colon; rectum; and anus (external orifice).

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Salivary glands Parotid Submandibular Sublingual

Pharynx Tongue

Oral cavity

Oesophagus Pancreas Liver Gallbladder Duodenum Common bile duct Colon

Stomach Pancreatic duct

Transverse colon Ascending colon Descending colon

Ileum (small intestine)

Caecum Appendix Rectum

Anus

Figure 23.3  The gastrointestinal tract The colon is a muscular tube lined with mucous membrane. It has tubular and longitudinal muscles that permit it to enlarge and contract in width and length. The major function of the colon is the absorption of water and electrolytes in the proximal half, and storage of faeces in the distal half until defecation occurs. The contents of the colon usually represent foods ingested over the previous four days, although most of the waste products are excreted within 48 hours of ingestion. The contents of the digestive tract (called chyme) are forced ahead in the tract by peristalsis. As much as 500 ml of chyme passes into the colon daily: most of this is absorbed in the colon, except for approximately 100 ml that is excreted in the faeces. The colon also secretes mucus that contains large amounts of bicarbonate ions. The mucus lubricates faeces, facilitating its evacuation. The mucosa is protected from mechanical and chemical injury by the mucous secretions. Bacterial acids are neutralised in the alkaline secretion, allowing constant putrefaction of whatever proteins were not digested and absorbed in the small intestine. Irritation of the mucosa results in an increased output of mucus in an attempt to dilute and remove the irritant. The result is frequent stringy loose stools.

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Transverse colon

Right hepatic flexure

Left splenic flexure

Ascending colon

Descending colon

Caecum Sigmoid colon Appendix

Rectum

Figure 23.4  Anatomy of the large intestine Source: Adapted from: https://www.allposters.com/-sp/This-IllustrationDepicts-the-Anatomy-of-the-Large-Intestine-Colon-Posters_i9013176.htm

Faeces consist of 75% water and 25% solid matter. The organic components consist of undigested food residue, digestive secretions and enzymes, dead cells, bile pigments and mucus. Of this mass, 30% is bacteria and 30% is fat. The nature of the diet does not change the contents of the stool except for the amount of cellulose present. Two defecation reflexes normally stimulate defecation. The intrinsic defecation reflex is stimulated by distension of the rectum. This happens when faeces and gas are propelled by peristalsis into the rectum from the descending colon. The second reflex, the parasympathetic defecation reflex, is involved when nerve fibres in the rectum are stimulated; parasympathetic signals are transmitted to the spinal cord and then back to the sigmoid colon and rectum. These signals intensify peristaltic waves, relax the internal anal sphincter and intensify the intrinsic defecation reflex. The external anal sphincter is under voluntary control after the age of about three. When the urge to defecate is felt, the individual may suppress it until the time is more convenient for him or her to go to the toilet and defecate. The ability to suppress the urge, however, only operates within certain limits; after a time the urge may become so powerful that it is irresistible.

Vomiting The vomiting centre is situated in the medulla oblongata. In response to stimulation, this centre sends messages to the diaphragm, abdominal muscles, stomach and oesophagus. The result is relaxation of the muscles of the stomach and oesophagus while the pyloric sphincter contracts. At the same time the diaphragm and abdominal muscles contract against a closed glottis to exert pressure on the stomach from above and below, ejecting the contents upward through the relaxed oesophageal sphincter and pharynx, and through the mouth, known as ‘vomitus’.

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Causes of vomiting

The following can stimulate the vomiting centre: • Stretching of a hollow organ (eg gastric dilation) • Inflammation of an organ (eg gastritis, hepatitis, appendicitis) • Irritation of the gastric mucosa by emetics (eg salt solutions) and poisons (including food poisoning) • Lesions of the stomach (eg ulcers) • Radiation and chemotherapy. The vomiting centre may be directly stimulated by abnormal substances in the blood or by reflex activity in the brainstem such as the following: • Irritation of the semi-circular canals of the inner ear (eg car, sea or air sickness, Ménière’s syndrome) • A sight or odour which may be so repulsive as to cause vomiting • Emetics (eg Ipecacuanha, Antabuse, if taken concomitantly with alcohol) • Narcotics such as morphine • Toxins, such as alcohol • Metabolic disorders (eg hypoglycaemia) • Uraemia, ketosis, Addison’s disease • Pressure on the vomiting centre due to raised intracranial pressure • Psychological factors, which include hysterical vomiting, bulimia and irritable bowel syndrome.

Nursing assessment of elimination To assess elimination in a patient, nurses need to note the factors described below.

Urine The observation and testing of urine is one of the first procedures that a nurse learns to do, but it is also one of the most important screening procedures done during assessment of a patient in the primary healthcare clinic and hospital situation. This screening will consist of a subjective and an objective assessment. Subjective assessment

This relates to information as provided by the patient about the following: • The act of micturition. Is there pain or burning? Is the patient straining on micturition? • The nature of the urine stream. Is it strong or weak? • The urine itself. Type of smell, if any, colour, amount, and any deposits? • The effect of urine on the genital area and around. Is there skin irritation or not? Is there staining of the person’s underwear? Objective assessment

This is done to: • determine colour and odour

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• determine clarity and the presence of deposits after the urine has stood for a while • determine specific gravity (SG) – this is the weight of a given volume of urine as compared to the weight of an equal amount of water; it is measured with a urinometer. Biochemical tests

Various makes of test strips are available in the market. These have between one and nine coloured pads that contain enzymes or reagents that will react and change colour when dipped into the urine. Every container has a colour-coded chart, with which the test strip is compared to determine the result. The timing that is specified on the container must be adhered to in order for the test to be accurate. The test strip will evaluate the following: • Sugar (glucose) is not normally found in urine. If present, the strip will change colour according to the amount of sugar present. • Ketones in the urine will turn the pad on the test strip to the designated colour. Ketones may indicate diabetic ketoacidosis. • Nitrates in the urine can be detected with a test strip and are the result of nitrateforming organisms that cause infection of the urinary tract (eg E coli, salmonella, staphylococci, Proteus, Klebsiella). A negative result does not exclude urinary tract infection by other non-nitrate producing organisms. A fresh early-morning specimen is the best to detect any bacteriuria. • Leucocytes (intact or lysed, ie pus cells) can be detected with a test strip. Elevated excretion of leucocytes indicates inflammation of the kidneys and lower urinary tract. An early-morning sample will provide the best indication. • Blood not visible to the naked eye (occult blood) can be detected by the sensitive chemical test incorporated in the test strip. Gross haematuria will be visible as a red discoloration of the urine. Discoloration will start when there is more than 0.5 ml blood in a litre of urine. This might indicate glomerulonephritis, renal cancer, bleeding disorders in urinary tract, cystitis, calculi, tumour, etc. • Proteins commonly found in urine are serum albumin and serum globulin – albumin being by far the most common of proteins. The reagent strip will determine the presence of protein in the urine. • pH can be numerically read on the colour chart according to the colour change on the test strip. A pH of 7 is neutral; a higher pH indicates alkaline urine and a lower pH indicates acid urine. • SG can also be numerically read on the colour chart according to the reaction on the strip. • Bilirubin and urobilinogen are the catabolic products of spent erythrocytes – none or very small amounts are normally excreted through the kidneys. • Both leucocytes and nitrates have a good predictive value. If both tests are negative, this strongly predicts the absence of urinary tract infection. If either or both are positive, then the specimen must be sent for microscopy, culture and sensitivity. Laboratory tests

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• Culturing of microbes and determining the sensitivity of microbes to antibiotics • 24-hour specimens to determine daily excretion of various substances such as electrolytes, hormones or drugs. Normal urine

Urine is a complex watery solution with organic and inorganic substances of which most are waste products from metabolism of food and body cells. The normal characteristics of urine are summarised in Table 23.1. Table 23.1  The characteristics of normal urine Characteristic

Observations Physical properties

Colour and transparency

Clear, straw coloured or pale yellow

Reaction

Slightly acid on a normal diet

Specific gravity (SG), (note: water SG is 1.000)

1 015–1 025 (on a moderate fluid intake according to the amount of solids in it) or 1.005–1.035

Deposits

None present in warm acid normal urine. If clear when passed, deposits that appear later will not be of pathological significance. Cloudiness is due to bacteria or crystals

Odour

Characteristic (described as aromatic) but not offensive Mild smell of ammonia is due to the presence of urea

Daily amount

Adults 1 000–1 500 ml; children (10 years) 600 ml; babies 180 ml. The amount of urine passed is in direct relation to fluid intake Chemical constituents

Water

95%

Solids

3.7% dissolved in water and thus cause urine to be heavier than water. This includes nitrogenous substances (urea, creatinine, uric acid, urates and ammonia)

Inorganic salts

Chlorides, phosphates, sulphates, oxalates of sodium, potassium and calcium and the pigment urochrome

Table 23.2  Normal variations found in the urine Characteristics

Variations

Causes

Colour and transparency

Amber to brown

Concentrated urine with high SG due to dehydration

Light straw to colourless

Dilute urine with low SG, meaning that little fluid has been lost from the body, as ➙ on cold days; can also mean that

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Characteristics

Variations

Causes the individual is taking in large volumes of fluid, which is making the urine dilute. Dilute urine may also be seen in individuals who are on diuretic therapy

Reddish colour

Large quantities of reddish-coloured foods, such as beetroot, senna and rhubarb taken in the diet

Orange and/or green colour

Cakes and sweets containing food dyes in the diet

Dirty cloudy colour

Infection of the urinary tract

Blue colour

Some medications (eg De Witt’s pills)

Alkaline reaction

Diet containing a lot of vegetables, legumes and citrus fruit Infection Vomiting

Acidic reaction

High protein diet Dehydration Cranberry juice

Specific gravity (SG)

Varies in accordance with intake of fluid, and therefore 1 004 and 1 030 can be normal

Due to lower fluid intake during the night, urine volume will be less and more concentrated in the morning with an elevated SG reading

Deposits

Cloudiness and deposits Whitish deposits (phosphates)

Happens in alkaline urine due to the presence of phosphates, which will disappear when urine is acidified Also due to bacteria or crystals

Granules (especially in cold days) Pinkish-white colour

Due to urate crystals that appear particularly when the urine is concentrated

Reaction

Table 23.3  Abnormalities found in urine Characteristic

Abnormality

Cause

Colour

Smoky

Small amount of blood

Red

Large amount of blood

Port-wine

Haemoglobin as a result of haemolysis Myohaemoglobin (muscle damage) Porphyrins due to faulty metabolism of haemoglobin in the liver (may only turn red after urine has been standing for some time) ➙

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Characteristic

Abnormality

Cause

Yellow-brown, brown-green with a yellow froth

Bile Bacteriuria, E coli, pus

Opalescent, milky

Urinary tract infection

Orange Black

Drugs (eg rifampicin)

Reaction

Alkaline

Bladder infection as may be indicated by a persistently alkaline (7–8) reaction in a fresh specimen

Odour These may also be a smell of antibiotics or foodstuff

Ammonia

Bladder infection.

Fishy

Bladder infection caused by E coli

Sweet (acetone)

Diabetes mellitus, starvation. The odour is caused by the presence of ketones, which are formed when body fat is broken down to provide nourishment for the tissues

Deposits

Yellow

Bile-stained

Thick yellow and wavy

Pus

Red/ chocolate in colour

Blood

Polyuria (urine above 3 litres per day)

Diabetes mellitus, chronic nephritis, diabetes insipidus, diuretics (eg furosemide)

Oliguria (below 500 ml per day)

Acute renal failure

Anuria

Acute renal failure

Low (< 1 005) Chronic renal failure

Diluted urine due to polyuria, high water intake, diuresis

Fixed (1 010)

Serious degree of renal failure

High (> 1 025) Diabetes mellitus

Concentrated urine due to insufficient water intake, dehydration

Volume

Specific gravity

➙

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Characteristic

Abnormality

Cause

Biochemistry

Glycosuria

Raised blood sugar (hyperglycaemia), diabetes mellitus, pregnancy and lactation, excitement, shock, thyrotoxicosis, cortisone therapy, Cushing’s syndrome

Ketonuria

Ketosis as a result of abnormal fat metabolism due to starvation; diabetes mellitus; high-protein, high-fat, low-carbohydrate diet

Albuminuria

Nephritis and nephrosis, toxaemia of pregnancy

Proteinuria

Strenuous exercise, nervous tension, febrile diseases, congestive cardiac failure

Haematuria

Acute nephritis, pyelitis, cystitis, acute attack of high blood pressure, tumours or tuberculosis of urinary tract, trauma, bilharzia

Urobilinogen

Altered bile pigment absorbed from the gut and excreted by the liver in bile. With large amounts, or with inability of the liver to secrete it, it accumulates in the blood and then is excreted via the kidneys in the urine

Choluria

Toxic obstructive and infective jaundice and cirrhosis of the liver

Pyuria

Urinary tract infection

Obtaining a sample of urine for analysis

It is a nurse’s responsibility to obtain and dispatch (where indicated) a sample of urine in such a way that the reliability of the results will be ensured. Urine specimens should ideally be obtained early in the morning. Great care must be taken when obtaining a urine specimen for analysis to prevent contamination with vaginal discharges including blood, for example, in the menstruating woman. A tampon can be inserted in this case, or a very careful midstream specimen taken. For a microscopy, culture and sensitivity test, a midstream specimen should always be obtained. Catheterisation to obtain a specimen is not advisable as this creates a route for the introduction of bacteria into the urinary tract. Paediatric urine-collecting bags are available to obtain urine samples from infants. The bag has an adhesive disc around the inlet opening that can be fixed around the genitalia of the infant (male or female). On removal of the bag, the adhesive disc can be folded over to seal the bag and prevent the contents from spilling out during transportation. The bag can be clearly marked before application. The specimen can be used for either ward or laboratory testing. The contents can also be poured into a sterile container for dispatch to a laboratory. Suprapubic aspiration using a needle and syringe to obtain a specimen of urine is sometimes done in infants.

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Other methods of urine collection • Midstream clean catch • Catheterised sample • Suprapubic or supination • In-out collection. Urine should be collected using aseptic technique and must be sent promptly to the laboratory.

Faeces Observation of stool

Inspection of faecal characteristics yields information relating to alterations in the nature of elimination. Various factors including information obtained from the patient can have an influence on the diagnosis in relation to elimination patterns and characteristics of stools. Table 23.4  Characteristics of faeces Characteristic

Normal

Abnormal

Cause

Colour

Infant: yellow Adult: brown

White or clay-like Black or tarry (melaena)

Absence of bile Iron ingestion or bleeding of the upper gastrointestinal tract Haemorrhoids Bleeding of the lower gastrointestinal tract Malabsorption of fat in cases where the bile to emulsify fats is not available

Red Pale with fat (steatorrhoea)

Odour

Pungent: depending on food type

Foul smelling; malodorous

Infection Blood in faeces

Consistency

Soft but formed

Liquid

Diarrhoea, reduced absorption Constipation

Hard Frequency

Varies: Infants: 4–6/day if breastfed; 1–3/ day if bottle-fed Adult: Daily or 2–3 times/week, depending on the diet

Infant more than 6 times a day or less than once every 1–2 days Adult more than 3 times a day or less than once a week

Hypermotility or hypomotility Hypermotility or hypomotility ➙

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Characteristic

Normal

Abnormal

Cause

Shape

Resembles diameter of rectum (cylindrical)

Narrow, pencilshaped Flat, ribbon-like

Obstruction Rapid peristalsis Hirschsprung’s disease

Constituents

Undigested food, pus, foreign bacteria, fat, bile pigment, cells lining intestinal mucosa

Flat, ribbon-like or grooved

Hirschsprung’s disease and tumour or large haemorrhoids Infection, swallowed objects, irritation, inflammation, worm infestation

Internal bleeding, mucus, worms

Obtaining a stool specimen

A stool specimen for assessment in the ward or clinic can be saved in the bedpan in which it has been passed. Factors that influence defecation

The following factors influence defecation: • Diet. Faecal volume is determined by adequate intake of bulk (cellulose, fibre). Irregular eating habits will impair regular defecation. Persons who eat at regular times usually have a regularly timed, physiologic defecation response to food intake and a regular pattern of peristaltic activity in the colon. Inability to digest certain foods or allergies may cause watery stools. • Fluid. High intake of roughage (bulk) without sufficient intake of fluids will cause constipation. With inadequate intake or excessive fluid losses, the body has to reabsorb fluid from the chyme as it passes along the colon. The chyme becomes drier than normal and the result is hard faeces. Reduced intake of fluids will slow the passage of chyme along the intestines, during which reabsorption of fluid will also be increased. • Lifestyle. Early bowel training plays an important role in the habits of defecation in later life. The availability of toilet facilities, embarrassment about odours and the need for privacy also affect faecal elimination patterns. • Age. Age affects the character of faecal elimination and its control. The very young cannot control elimination until the neuromuscular system is developed (usually 2–3 years of age). The elderly experience changes that will influence evacuation of the bowel such as the following: –– Atony of the smooth muscle of the colon results in slower peristalsis and constipation. –– Decreased tone of the abdominal muscles results in less pressure being exerted during bowel evacuation. –– Lessened control of anal sphincter muscles may result in an urgency to defecate. • Muscle tone. Muscular activity stimulates peristalsis and therefore facilitates the movement of chyme along the colon. Weak abdominal muscles will make it difficult to increase the intra-abdominal pressure during defecation or to control defecation. 495

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• Medications. Many drugs have side effects that influence normal elimination. Some can cause diarrhoea (eg antibiotics) and others constipation (eg morphine, codeine and other analgesics, large doses of certain tranquillisers). Some medicines are given because they directly affect elimination. Laxatives stimulate bowel activity and promote faecal elimination. Medications can be given to soften stool to facilitate defecation or to treat diarrhoea. • Psychological factors. Some diseases that involve diarrhoea (eg ulcerative colitis) have a psychological component. Angry or anxious persons experience increased peristaltic activity and subsequent diarrhoea. In contrast, depressed people may experience slower intestinal motility that results in constipation. • Diagnostic procedures. On various occasions, a patient will not be allowed food or fluid after midnight preceding a diagnostic procedure, especially if it concerns visualisation of the colon (eg sigmoidoscopy). The patient is often given a cleansing enema just prior to the examination. In these instances the person will not defecate normally until he or she has resumed eating. If barium was used during a radiological examination, it will harden if left in the colon and may lead to constipation or even impaction. • Anaesthesia and surgery. The normal movement of the colon is stopped or slowed down by agents used for general anaesthesia, by blocking parasympathetic stimulation of the muscles of the colon. Persons who have regional or spinal anaesthesia are less likely to develop this problem. Direct handling of the intestines during surgery will cause temporary cessation (24–48 hours) of intestinal movement, namely paralytic ileus. • Pain. Pain or discomfort during defecation will often be the reason why someone suppresses the urge to defecate in order to avoid the pain, for example following haemorrhoidectomy. The consequence is constipation. • Irritants. Various substances such as spicy food, bacterial toxins or poisons can irritate the intestinal tract. These produce diarrhoea and large amounts of flatus. • Sensory and motor disturbances. Head injuries, injuries of the spinal cord and impaired mobility can decrease the stimulation for defecation. Impaired mobility will limit a person’s ability to respond to the urge to defecate when he or she is unable to reach a toilet or summon assistance. Poor functioning of sphincters may result in faecal incontinence. Abnormalities of defecation

The following are abnormal aspects of defecation: Constipation Constipation refers to the passage of a small, dry, hard stool or of no stool for a while. Careful assessment of a person’s habits is important before a diagnosis of constipation is made. A person’s regular defecation pattern may be that it takes place only a few times a week – in such a case it would not necessarily be constipation if the person misses a day or two. Associated with constipation is difficulty with evacuation of stool and increased effort or straining of the voluntary muscles of defecation. In addition to causing discomfort, constipation can be hazardous. Straining during defecation places stress on abdominal and perineal sutures if present, and will rupture them if the pressure is sufficiently great. Straining is usually accompanied by holding the breath. 496

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This is the Valsalva manoeuvre, which can cause serious problems for persons with heart and respiratory disease and brain injury, as it creates an increase in intrathoracic and intracranial pressures. Pressure can be reduced to some degree if the person exhales through the mouth during straining. Avoiding any straining is, however, the best precaution. The following are factors that might cause constipation: • Ignoring or inhibiting normal defecation reflexes tends to progressively weaken these conditioned reflexes, and, when habitually ignored, the urge to defecate is ultimately lost. • Overuse of laxatives also inhibits natural defecation reflexes. The habitual user eventually requires larger or stronger doses of laxatives as they have a progressively reduced effect with continual use. • Inappropriate diets, such as bland and low-roughage ones, lack bulk and will not provide sufficient residue of waste products to stimulate the reflex for defecation. Low-residue foods (eg rice, eggs, lean meat) move more slowly through the intestinal tract. Increasing fluid intake with such foods increases their rate of movement. • Diseases of the anus, rectum and colon, for example bowel obstructions, carcinoma of the colon, diverticular disease of the colon and painful lesions of the anus can cause constipation. • Insufficient exercise, which occurs when patients are on prolonged bed rest, for example, affects regularity. Lack of exercise is usually associated with lack of appetite and a possible lack of roughage in the diet. • Psychic causes such as strong emotion may cause constipation by inhibiting intestinal peristalsis through the action of epinephrine and the sympathetic nervous system. • Stress can also cause a spastic bowel. • Medication and chemical agents such as calcium-containing antacids cause constipation. • Age is also a factor in constipation as activity and muscle tone are reduced with age. • Pressure from outside the colon (eg gravid uterus, ovarian cysts) is also a factor. • Post-general anaesthesia is another cause of constipation. Faecal impaction Faecal impaction is a mass or collection of hardened, puttylike faeces in the folds of the rectum. It results from prolonged retention and accumulation of faecal material. In severe cases it may extend well up into the sigmoid colon and beyond. Faecal impaction is recognised by the passage of liquid faecal seepage (diarrhoea) and no normal stool. The liquid faeces seep out around the impacted mass. Impaction can also be assessed by digital examination of the rectum. This should be done gently because stimulation of the vagus nerve in the rectal wall can slow a patient’s heart rate. Other symptoms that may be experienced are the following: • Rectal pain • Frequent desire to defecate, which is non-productive • Anorexia 497

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• Distended abdomen • Nausea and vomiting. Diarrhoea Diarrhoea is the passage of liquid faeces and an increased frequency of defecation. It results from rapid movement of faecal contents through the large intestine with the result that the time available for reabsorption of water and electrolytes from the chyme is reduced. The individual with diarrhoea finds it difficult to control the urge to defecate for very long. The threat of incontinence is very real and often a source of embarrassment. Spasmodic and piercing abdominal cramps often accompany diarrhoea. Other symptoms are the following: • Passing of blood or mucus • Nausea and vomiting • Irritation of the anal region with persistent diarrhoea • Weakness • Fatigue • Malaise • Emaciation following prolonged diarrhoea. Causes of diarrhoea • Infections (eg salmonellosis, cholera) • Toxins (eg staphylococcal toxins) • Psychological stress and anxiety • Medication (eg antibiotics, iron derivatives (also causes constipation), purgatives, digitalis) • Allergy to or intolerance of some foods and fluids • Chemical substances (eg arsenic and organophosphates) • Diseases of the gastrointestinal tract (eg malabsorption syndrome, Crohn’s disease, chronic pancreatitis post-gastrectomy) • Diseases outside the gastrointestinal tract (eg nutritional deficiency diseases such as pellagra, and endocrine and metabolic disturbances such as uraemia and thyrotoxicosis). Faecal incontinence Incontinence may occur irregularly or at specific times, such as after meals. It is usually associated with impaired functioning of the anal sphincter or its nerve supply, such as spinal cord injury. Faecal incontinence is an emotionally distressing problem that may lead to social isolation of the individual. Flatulence Flatulence can be caused by the following: • The action of bacteria on the chyme in the large intestine • Swallowed air • Gas generated by some foodstuffs (eg onions, beans, cabbage) • Constipation • Codeine, barbiturates, narcotics and other drugs that decrease intestinal motility • Anxiety states 498

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• Anaesthesia • Dietary changes • Reduction in activity may cause distension post-operatively. An adult normally forms 7–10 litres of flatus in the intestine every 24 hours. The gases include carbon dioxide, methane, hydrogen, oxygen and nitrogen. Most of the gases swallowed are expelled through the mouth by eructation or belching. Normally all but 0.6 litres of the gases produced are absorbed into the intestinal capillaries. Excessive flatus in the intestines and stomach leads to stretching and inflation (distension).

Vomiting Vomiting is usually an indication that there is something amiss. Most individuals vomit occasionally due to overeating, indigestion or having consumed too much alcohol. However, if the patient is vomiting frequently or regularly, the situation should be investigated. Observable outcomes in the vomitus

Nurses should note the following: • The quality, colour, reaction and consistency of the vomitus • The presence of mucus, blood, bile (green and greenish-yellow), worms, or undigested food in the vomitus • The time of vomiting in relation to food and medicine (see Table 23.5) • Whether vomiting was accompanied or relieved by pain. If vomiting relieves pain, it may indicate the presence of gastric ulcers, cancer or dyspepsia (cramp-like abdominal pain accompanied by vomiting is a sign of colic). • The frequency and duration of vomiting. Also evaluate the patient for the presence of the consequences of vomiting: • Dehydration • Sodium and potassium depletion • Metabolic alkalosis • Aspiration pneumonia in unconscious patients where the valve action of the glottis is not functioning • Erosion of the teeth as a result of the acidic stomach contents (eg from chronic vomiting in bulimia) • Tears in the oesophageal and gastric mucosa. Table 23.5  Time of vomiting Time

Cause

Early morning before eating

Pregnancy Alcoholic gastritis

After eating

Gastric ulcers, gastritis, dyspepsia, nervousness (amount usually too small to cause undernourishment) ➙

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Time

Cause

Not associated with food, pain or nausea

Raised intracranial pressure Dilation of stomach

After taking medicine

Irritation of gastric mucosa by the drug Sensitivity or toxic reaction to the drug

During or after meal

Psychogenic Pyloric ulcer

Epidemics of sudden explosive vomiting 4–6 hours after ingestion or even 12–48 hours after ingestion

Food poisoning Viruses Toxin-producing organisms (eg Staph. aureus, salmonella and shigella)

Common clinical problems related to the maintenance of elimination Facilitating micturition and regular defecation Hospitalisation and illness, as well as prescribed medical therapies, may interfere with a patient’s normal voiding habits. The facilitation of elimination is an important part of a nurse’s role, and several factors should be taken into consideration. Table 23.6  Facilitation of micturition and defecation Facilitation

Micturition

Defecation

• Ensure privacy • Allow sufficient time • Suggest reading or listening to music • Promote muscle relaxation with sensory stimuli: –– Pour warm water over perineum of females –– Suggest sitting in a warm bath –– Apply a hot water bottle to the lower abdomen –– Turn on running water within hearing distance to mask any sounds for those who find them embarrassing –– Relieve physical and emotional discomfort to decrease muscle tension –– Provide analgesics as prescribed

• Present a bedpan at regular intervals • Ensure privacy • Allow sufficient time • Suggest reading or listening to music • Turn on running water to mask sounds • Relieve physical and emotional discomfort such as tight clothing, or provide a peaceful environment

mechanisms

Relaxation

➙

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Facilitation

Micturition

Defecation

Positioning

• Allow the patient to assume a normal position (ie standing for males and sitting/squatting for females) • Use bedside commodes, bedpans or urinals for bedridden patients • Suggest the use of hands to push on the pubic area, or to lean forward to increase intra-abdominal pressure and external pressure on the bladder

• Allow the patient to assume a normal sitting position whenever possible • Use bedside commodes or bedpans for bedridden patients • Take patients to the toilet in a wheelchair if possible

Timing

• Tell patients never to ignore the urge to void. This may make the desire vanish or pass and will increase the difficulty in starting to void. Provide assistance immediately • Offer assistance to eliminate at regular intervals (eg on awakening, before/after meals, at bedtime)

• Encourage defecation when the urge is recognised • Establish a regular bowel elimination pattern • Stimulate mass peristalsis (eg with a hot drink, or a light snack) • Help patients who already have well-established routines to maintain them

During bed rest

• Warm the bedpan to prevent contraction of perineal muscles, which will inhibit voiding • Simulate the normal voiding position by elevating the head of the bed to a Fowler’s position and have the patient flex the hips and knees. A small pillow or rolled towel positioned at the small of the back may increase physical support and comfort • If confined to bed, assist a female patient into an upright position on the bedpan with legs hanging down (if allowed) over the edge of the bed with feet resting on a chair. A male patient can lie on his side when confined to bed to enable him to use the urinal

• Warm the bedpan • Simulate the normal position as closely as possible

Nutrition and fluids

• Adequate fluid intake is necessary to ensure output and should not be restricted because a patient chooses to avoid passing urine, for example because of dysuria (painful urination)

For constipation • Increase daily fluid intake • Increase intake of hot fluids and fruit juices (especially prune juice) ➙

mechanisms

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Facilitation

Micturition

Defecation

• Adequate intake of fluids is important to prevent some of the complications of bed rest

• Increase intake of fibre in the diet (eg raw fruit, prunes, bran products and whole grain cereals and bread). Only as a last resort should stool softeners and laxatives be taken

mechanisms

For diarrhoea • Give small amounts of bland food. The patient may be reluctant to eat or drink as this stimulates the gastro-colic and duodenal reflexes, inducing more stool • Increase potassium intake to compensate for losses • Avoid very hot or cold fluids as these stimulate peristalsis • Avoid highly spiced foods and high-fibre food as these aggravate diarrhoea For flatulence • Limit carbonated beverages, the use of drinking straws and chewing gum – all increase the intake of air • Avoid gas-forming foods (eg cabbage, beans, onions and cauliflower) Exercise

• Important for the prevention of the complications of bed rest, such as cystitis

• Helps stimulate normal motility of the intestines –– Encourage early ambulation post-surgery –– Strengthen weak abdominal and pelvic muscles (which impede normal defecation) with isometric exercises

Prevention of constipation • Regular times should be instituted to go to the toilet, for example after breakfast when the gastro-colic reflex is strongest. Allow for sufficient time and privacy. • A hot drink early in the morning may initiate the mass peristaltic movement that leads to bowel evacuation. • Regular exercise will help to stimulate normal motility of the intestines. • The diet of the person should contain roughage such as unprocessed cereals, raw and stewed fruit, brown bread, breakfast cereals and increased fluid intake. 502

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Treatment of constipation with cathartic therapy

Cathartics are substances that stimulate evacuation of the bowel (purging). Laxatives have a mild effect which loosens the bowels without causing abdominal cramps and watery stools. Purgatives have a stronger effect and are often accompanied by abdominal cramps and dehydration. Prolonged use of purgatives may cause hypokalaemia and inflammation of the bowel. A large dose of a laxative may have a purgative effect. Cathartic therapy is indicated for the following: • Constipation • Emptying the bowel before abdominal radiography or bowel surgery • Ensuring an empty rectum before the birth of a baby. Cleansing of the bowel can be obtained in the ways described below. Increasing faecal mass

Various substances can be taken orally to increase the bulk of the stool. Agar (from seaweed) becomes jelly-like when mixed with fluid in the gastrointestinal tract (eg Agarol). Seeds from various plantago species absorb water in the gastrointestinal tract to form a viscous substance (eg Agiolax granules, Metamucil). These agents can be used to correct both dry and loose stools. In the patient with an ileostomy, bulking agents are often used to thicken the drainage and to prevent the leaking out of watery faeces. Bulking agents must never be used in patients with impacted faeces. Faecal softeners

These agents are used to soften a hard, shrunken stool. Liquid paraffin is a mineral oil that is not absorbed. It acts as a lubricant and softens the faeces in the colon. It is considered a mild laxative but continued use may be harmful. It may interfere with digestion and absorption from the small intestine with resultant deficiency of fat-soluble vitamins. Non-irritating faecal emulsifying agents (eg dioctyl sodium sulphosuccinate) lower the surface tension in the faeces and thus increase fluid penetration. Combined with bowel stimulants, they form effective purgatives for use in radiography. Colonic stimulants

Colonic peristalsis can be stimulated by laxatives or purgatives. Laxatives • Synthetic laxatives such as bisacodyl (eg Dulcolax) can be administered orally (act within six to 12 hours) or rectally (act within one hour). • Dihydroxyanthraquinone is another synthetic laxative resembling the natural anthraquinone laxatives. • Phenolphthalein is a non-toxic laxative even in large doses. It acts within five hours and its action lasts a few days, therefore it is valuable in chronic constipation. It is an ingredient of many purgative mixtures (eg Agarol). • The anthraquinone group of laxatives includes rhubarb, aloes, cascara and senna. These substances stimulate the neuromuscular apparatus of the colon – their action closely imitates normal peristalsis and defecation and is therefore not harmful. The action of these agents is delayed for approximately nine hours after ingestion. 503

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• Senna causes no mucosal irritation or systemic toxicity. It is of special value in the treatment of chronic constipation in the aged. It can be used in the re-education of the bowel in chronic constipation. Senna may cause hypomotility of the bowel if used regularly over a number of years. The neurones in the submucosal ganglia cannot function without the stimulation of senna. • Cascara has a nauseating, bitter and lasting taste. It is usually administered as an elixir and is also suitable for the treatment of chronic constipation. Both these agents (senna and cascara) will cause abdominal cramps if too large a dose is taken. The optimal dose should be determined for each person. When the constipation has been corrected, the dose must be gradually diminished until it is finally discontinued. • Lactulose is a synthetic disaccharide that is split by bacterial action in the bowel and then acts as a laxative (eg Duphalac). It is used to control the symptoms of hepatic encephalopathy. Purgatives • Purgatives that cause loose, watery stools and abdominal cramps should be avoided, for example saline purgatives (such as fruit salts, Epsom salts, Milk of Magnesia) that increase faecal bulk by retaining sufficient water in the intestine to hold them in osmotic equilibrium. The contents of the small intestine then are abnormally liquid, which stimulates strong peristalsis and evacuation of liquid stools. These agents usually act an hour after ingestion. Excessive use will cause hypokalaemia. • Castor oil is a drastic purgative that is first digested in the small intestine before it can stimulate the intestinal wall to work out a strong peristaltic movement that empties the intestine completely, thereby causing constipation. Its main use is in food poisoning to rid the bowel of organisms and toxins and just before labour. • Vegetable laxatives consist of jalap and colocynth that are drastic purgatives. They cause enteritis and dehydration if given in overdose. • Many traditional medicines, such as isihlambezo, contain drastic herbal purgatives. If these mutis are taken in excess, they can be dangerous, causing severe dehydration, renal failure, systemic toxicity and even death. Enema

An enema is an injection of fluid into the large intestine. It is usually given if immediate evacuation of the colon is required for some reason. A conventional enema makes use of a fairly large quantity of fluid. Micro-enemas or disposable enemas of small size are currently available in pharmacies. Bowel washout

Bowel washout is done to cleanse the colon and rectum. This can be done to remove any blood from the large bowel in cases of liver failure and bleeding oesophageal varices. This prevents the absorption of ammonia (formed by the breakdown of protein in the blood) that causes encephalopathy. Bowel washout is also done before diagnostic procedures or surgery of the bowel. Treatment of faecal impaction

Manual removal of a faecal impaction entails breaking up of the faecal mass and then manually removing the pieces. This is a distressing and uncomfortable procedure. Care 504

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must be taken to avoid injury of the bowel, mucosa and sphincter. An emptying enema, laxatives and a balanced diet must always follow this procedure. Treatment of diarrhoea

Intake of fluids and food should be encouraged. Ingestion of food and fluids stimulates the gastro-colic and duodeno-colic reflexes, thus inducing more stools, so the individual may be reluctant to eat and drink. • Intake of fluids and electrolytes through the oral or parenteral route is extremely important, especially if the patient is dehydrated. Avoid very hot or cold fluids, as these will stimulate peristalsis. Oral rehydration therapy (ORT) can be very useful in preventing dehydration. A cup of ORT should be taken after every loose stool. • Eating small amounts of bland foods or a clear fluid diet can be of value as these are more easily absorbed. Easily digestible carbohydrate (eg well-cooked refined cereals prepared with water and sweetened with honey, sugar or glucose) can be given. When the diarrhoea has stopped, soups and milk dishes can be gradually introduced. Convalescence will proceed through a low-residue, light and then full diet. Encourage the intake of foods high in potassium. Only in severe cases of diarrhoea should food be withheld and parenteral/intravenous fluids given. • Treatment of symptoms consists of inhibition of peristalsis by the oral administration of drugs such as codeine or Lomotil/Kaopectin to stop the absorption of toxic substances that are formed in the bowel as a result of the putrefaction of proteins. • Ensure that the patient’s basic hygienic needs are met. • Specific antimicrobial treatment is sometimes administered on the physician’s prescription. Treatment of faecal incontinence

Faeces are acidic and contain digestive enzymes that are highly irritating to the skin. The skin area around the anus should therefore be cleansed and dried regularly and protected with zinc oxide or a similar ointment. If the problem is chronic, and not an isolated occurrence due to illness, the patient can be advised about various incontinence aids that are available, and carrying a deodorant spray may increase social confidence. Many individuals who suffer from faecal incontinence can have some form of surgical correction to restore the tone of the anal sphincter, and the patient should be encouraged to have the problem investigated, as it is extremely distressing to both patient and family. Treatment of flatulence

The patient who cannot expel gas through the anus may need to have a rectal tube inserted or an enema to remove it. Dietary measures may play an important role in the prevention of flatulence, for example exclusion of gas-forming foods, such as cabbage, onions and beans from the diet.

Nursing intervention during vomiting Remove dentures if present. Assist the patient by supporting his or her head. If any abdominal or chest wounds are present, the nurse should also support these. Hold the emesis bowl for the patient and remove used ones. A clean bowl should be available 505

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before the soiled one is removed. Rinse or clean the patient’s mouth after vomiting. Wipe hands and face, clean and replace dentures, change soiled linen and clothes, and provide something to drink where allowed. Do the necessary observations and save the vomitus for inspection if indicated. Notify the person in charge about the observations. Treatment of vomiting consists of first removing the cause: • Decompression (suction) of the gastrointestinal tract in cases of persistent postoperative vomiting • Discontinuation of medicines causing vomiting (eg Omnopon) • Administration of antispasmodic analgesics for colic. Anti-emetics are administered for nausea, motion sickness, radiation sickness, chemotherapy and pregnancy. These may be administered orally or intramuscularly, and some even rectally. Drugs that may be prescribed are the following: • Antihistamines with powerful anti-emetic action (cyclizine, Valoid) • Anti-emetic and antispasmodic (metoclopramide, Maxalon) • Phenothiazine tranquillisers (prochlorperazine, Stemetil).

Urethral catheter care An indwelling urethral catheter is a foreign object to the body and will therefore be associated with problems if left in situ for long periods. The nursing care must be aimed at optimising patient comfort, as well as limiting the complications of catheterisation. The catheter

There are different types of catheter available in the market today. Selecting the right one will depend on what it is needed for and for how long catheterisation will be required. Catheter selection is done according to the following three criteria: 1. Expected duration of insertion. Although a lot has been written about latex allergies, latex catheters remain a suitable choice for catheterisation of between seven and 10 days. For intermediate use (three to four weeks), catheters made of latex with silicone coating can be used. Long-term patients (six weeks to three months) should have a silicone or hydrogel catheter. 2. Consistency of urine. The smallest catheter size possible should always be used. 3. Bulb size required. A standard size bulb should be 5–10 ml. The 30 ml bulb is usually only indicated after urological procedures. The 30 ml bulb has a greater intravesicular displacement and thereby results in greater bladder irritability, bypassing and discomfort. The ideal size bulb for adults is 5–10 ml: 8–10 ml of sterile water is used in a catheter marked for 5–10 ml, as 3–4 ml remains in the channel. Inflating the majority of 30 ml bulbs with only 10 ml of water normally results in a lopsided bulb that kinks the catheter, causing blocking, and it slips out easily during coughing or bladder spasm. Indications for urethral catheterisation

A distinction should be made between a patient who requires short-term catheterisation (eg the surgical patient) or long-term (permanent) catheterisation. Questions to be asked are: Why must the catheter be inserted, and for how long should it remain in situ?

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• Short-term catheterisation. This is used mostly for the surgical/hospitalised patient to monitor urinary output and to ensure continuous drainage without the sick/ sedated patient having to use a toilet or bedpan. As soon as the patient is stable, awake and ambulatory, the catheter should be removed. It remains the responsibility of the patient’s physician to order the removal of catheters. • Long-term/permanent catheterisation. These are the patients who need most care and can develop the complications mentioned below. Patients who are bedridden due to chronic illness, old age or neurological problems (cerebrovascular accidents, quadriplegia, etc) make up most of these cases. Care of catheterised patients and prevention of complications

General patient care Adequate hydration of the patient ensures a large volume of dilute urine. This will limit encrustation/gravel formation and flush out bacteria. The oral fluid intake must be at least 2–3 litres per day provided that the patient has no systemic (cardiovascular or renal) contraindications. The most common uro-pathogen is E. coli, which prefers alkaline urine, therefore acidifying the patient’s urine may prevent urinary tract infection. For this reason the regular use of Citrosoda or Effersol is not encouraged. Dietary measures can also help urinary acidification. Most vegetables and some fruits (not citrus products) yield alkaline urine, whereas meat, fish, poultry, eggs and cereals acidify it. Educate the patient with regard to the underlying principles of catheterisation and the importance of observing these principles. Catheter and genital care The responsibility of a nurse is as follows: • Ensure free drainage of the urine by avoiding twisting/kinking of the catheter or drainage bag tube. Fix the catheter preferably on the upper thigh. • In male patients, fix the catheter on the suprapubic area to avoid tugging or pulling. • The urine bag must always be lower than the pelvis of the patient to ensure adequate drainage by way of gravity. Should it be necessary to raise the drainage bag, for example with a bedridden patient who must be turned onto the other side, be sure to clamp the tube before raising the bag. Keep the tube clamped until the drainage bag is below the level of the bladder on the other side again. Check that the flow of urine is no longer obstructed. • Take extra care when moving or ambulating a patient. Watch the position of the tubing and bag at all times to prevent pulling on the catheter. To prevent injury to the urethral lumen or bladder wall, always disconnect the drainage bag and tubing from the bed frame before helping a patient out of bed. When possible, attach a leg bag to allow the patient greater mobility. • Perineal-genital care should be done at least twice daily. This is considered to be one of the most significant measures for reducing the incidence of infection. Secretions and encrustations may accumulate at the urethral orifice and this presents an ideal medium for pathogens that can then ascend the tract. The basic care is thorough washing of the area with soap and water. For the uncircumcised male patient, the foreskin must be retracted to clean well under it.

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• Special catheter care in addition to perineal-genital care may also be required, and this basically includes cleansing of the urethral meatus and catheter with an antiseptic solution and the application of an antimicrobial ointment at the urethral meatus. Unless specifically prescribed, no dressing is applied. Check the catheter care prescribed by your institution. • Always maintain a closed drainage system. Unnecessary disconnection of the urine bag must be avoided in order to limit contamination of this system. • Check that there are no leaks at the connection sites. • Keep the drainage bag off the floor by securing it to a hook or the bed frame. • Ensure that there are no loops in the tubing that hang below its entry into the drainage bag. • Utilise the surgically aseptic technique when emptying the drainage bag. The tube or connection used to drain the bag should not be contaminated and should be reattached appropriately when the bag has been emptied. • Empty the drainage bag at regular intervals so that it does not overfill and cause urine backup in the tubing, thus creating a reservoir for microbes. • Irrigation of the catheter may be useful to rid the system of the debris (mucus, blood, gravel) that causes blockage of the catheter. This must also be done in an aseptic manner. Routine washouts are avoided as they increase the risk of infection. • If there are systemic (rigors, fever) manifestations of an ascending urinary tract infection, urine can be sampled by aspiration through a special port in the tubing that is now part of most drainage bags. This will allow isolation of the specific bacteria involved as well as determining the antibiotics that will be effective (sensitivity). • Replacement of long-term indwelling catheters must be done at regular intervals. This will depend on the type of catheter used, the patient’s response to the catheter and also the specific requirements of the relevant institution. Silicone catheters should last for an average of three months. Sometimes temporary removal of the catheter is required to treat persistent/severe complications. Further urological assessment by the physician will be necessary if this happens. • Removal of a catheter is done for the above-mentioned reason or as soon as its purpose has been achieved (always on the order of the physician). If the catheter has been in situ for a long time, bladder training may be necessary. On removal of a long-term catheter, the patient will experience frequent urination until his or her bladder has regained its muscle tone. Taking increased quantities of fluid and initially trying to keep urine in the bladder for as long as possible may assist in regaining bladder tone. Most patients will experience a burning sensation in the urethra as a result of irritation by the catheter, but this will disappear after a few days. Increased quantities of fluid will minimise the burning by diluting the urine. It is vitally important that the nurse checks that the patient passed urine within eight hours after catheter removal – if not, the catheter may need to be replaced. • Assess and record fluid intake and output. Complications of urethral catheters Complications may arise during the use of urethral catheters.

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Short-term complications are as follows: • Urethral trauma. During insertion the balloon can be inflated when it is still in the prostatic urethra. It is essential that drainage of urine be seen before inflating the catheter balloon. Inadvertent traction on the catheter for some reason can also traumatise the bladder neck/urethra. Small (5 ml) balloons can be pulled out completely followed by quite severe urethral bleeding afterwards. • Infection. If a catheter is in situ for more than a week, it will be associated with urinary tract infection, even if it is only sub-clinical (bacteriuria). • Mechanical blockage. Catheters can be blocked with debris (blood, mucus, sediment, gravel) or due to kinking. The catheter needs to be checked regularly to ensure free drainage. Long-term complications are as follows (all of the short-term complications can also occur at a later stage): • Infection. Anything from haemorrhagic cystitis (macroscopic haematuria) to urethritis (purulent discharge around catheter) or urethral abscess is possible. If left untreated, an infection may ascend to cause acute pyelonephritis and subsequently renal scarring. This can eventually lead to renal failure. A peri-urethral abscess can break through the perineal skin causing a urethra-cutaneous fistula. • Calcification. Because the catheter is a foreign object in the urinary tract, it invites the formation of encrustations (the so-called eggshell calcifications) that can lead to bladder stone formation. More often, however, it causes gravel that can block the catheter. • Urethral dilatation. This can be an annoying problem in female patients with a chronic indwelling catheter. It causes urine to leak past the catheter and eventually the catheter can be expelled, even with a 30 ml balloon.

Functional bladder problems Bladder spasm can occur and is very painful. This can cause urine to leak past a catheter despite a patent lumen. Chronic infections can eventually lead to bladder contraction leaving a small-volume, non-compliant bladder. Urethral strictures

Owing to mechanical irritation and infection caused by the catheter, strictures (narrowing) can develop in male patients. The anatomical position of such strictures is usually at the meatus (where the catheter comes out) or at the penoscrotal junction where there is angulation of the urethra. Incontinence

Incontinence refers to the inability of a person to control his or her bowel or bladder movements. There are many reasons for this, and a proper assessment must be done before any treatment or care can be planned. Incontinence is often underreported, as many people regard it as being part of the normal process of ageing. People find it embarrassing to admit that they sometimes wet themselves, and the socially unacceptable nature of the problem also contributes to the fact that patients keep the problem to themselves. Lack of control over elimination is associated with an infantile state. 509

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Causes of incontinence Urinary incontinence can be caused by many factors, such as the following: • Stress incontinence is caused by laxity of the muscles of the pelvic floor and is common in women after childbirth. • Spinal injuries and brain lesions such as cerebrovascular accident can cause incontinence. • Incontinence may also be due to inadequate sphincter control and dribbling. • Nocturnal enuresis, or bedwetting, is usually associated with emotional problems in children. Sometimes the bed-wetter is simply a late developer. • Sedatives may cause bedwetting in the elderly. • Retention of urine may lead to overflow with incontinence. • The detrusor muscle of the pelvic floor may be unstable. Faecal incontinence is not a common occurrence, but may be caused by the following: • Constipation with impaction and diarrhoea overflow • Severe diarrhoea due to drugs • Sphincter incompetence • Neurogenic conditions, following spinal injuries • Psychological and behavioural disorders • Encopresis is a form of faecal soiling that is found in children between four and eight years of age, mainly boys, and may be a symptom of an underlying psychological problem. Care of a patient with incontinence Nurses should treat patients who are incontinent with patience. • Every effort should be made to maintain the dignity and privacy of the patient. • The patient will need a lot of emotional support until a satisfactory solution to the problem has been reached. It is extremely important for a full assessment to be done to identify possible causes that can be treated or eliminated. • Skin care becomes a major problem when a patient becomes incontinent. Unless the patient is kept meticulously clean and dry, severe skin rashes and ulcerations may occur as a result of the accumulation of urine, which is converted to ammonia, on the skin. The patient’s perineal area should be washed with soap and water, and dried thoroughly with a soft cloth. Clean, dry clothing and bed linen must be provided. Barrier creams, such as zinc oxide, can be applied to irritated skin to protect it from contact with urine or faeces. • Where indicated, a bladder/bowel-retraining programme can be instituted to improve the patient’s bladder and bowel control. This is usually an important aspect of the rehabilitation process following spinal injury. • There are various products on the market that will absorb the wetness and leave a dry surface in contact with the skin. These incontinence pads can be worn together with waterproof underwear. For males with urinary incontinence, a urinary sheath (condom) can be applied. The end is then attached to a urinary drainage system. This system is preferable to the insertion of a retention catheter as the possibility of infection is minimised.

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• The application of the condom drainage system should be done carefully in order to protect the skin. If worn for short periods, application can be done with an elastic tape only: some patients only require a condom appliance at night. If the condom is to be worn for extended periods, additional methods may be needed to secure the appliance. The manufacturer’s instructions should be consulted and followed when applying a condom drainage system, as they can be difficult to keep in place. A condom drainage system should be changed frequently and kept scrupulously clean; if not, infection may occur. • Only where there is no other solution should the patient be catheterised for urinary incontinence.

Essential health promotion and health education Nurses have a responsibility to educate patients on the facts described below. The significance of diarrhoea and vomiting cannot be overemphasised in South Africa. Each year thousands of infants and young children die as a result of neglected or inadequately treated diarrhoea and vomiting. Communities should be shown how to make a simple oral rehydration treatment solution using a one-litre cool-drink bottle: 1. One litre of clean tap water, or boiled water if the supply is not safe 2. Half a teaspoon of salt 3. Eight teaspoons of sugar 4. Orange juice to improve the flavour (optional). A feeding bottle or cupful of the solution should be given after each loose stool or vomiting episode. Even if the fluid is not kept down, some of the water, sugar and salt will be absorbed and will benefit the patient. Treatment with ORT is not confined to infants and young children – adult sufferers can also benefit from it. Diarrhoea and vomiting in infants and young children is often as a result of the inadequate hygiene of feeding bottles. Ideally, infants should be breastfed, and then the question of hygiene of feeding bottles does not arise. The promotion of breastfeeding is an important priority for health workers, especially in poor communities who may not have access to a clean water supply, and who can barely afford the cost of infant formula. If breastfeeding is not possible, mothers should be shown how to boil infant feeding bottles and teats, or alternatively how to sterilise them in a dilute solution of bleach. Water-borne diseases such as typhoid and cholera are important epidemic diseases in South Africa, especially in rural communities and in informal settlements where there is inadequate water supply, or the available water supply is suspect. Both of these serious illnesses present with diarrhoea and vomiting. It is therefore essential that health workers do not ignore cases of diarrhoea and vomiting, especially in the summer months. It is important for the community to be made aware of the need for a clean water supply. If the local water supply is not clean, the people need to be shown how to boil their drinking water, or alternatively how to sterilise it with a small amount of bleach. The rational use of laxatives and purgatives is an important topic for health education in the community. Generally, a balanced diet with adequate amounts of fibre

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will ensure regular bowel actions. The frequency of bowel action is usually related to the amount and type of food eaten, and it is not necessary to have a bowel action once a day in order to be in good health. The dangers of laxative abuse should also be brought to the attention of the community: the use of safe laxatives, such as fibre or bulk-forming ones, should be promoted. Many traditional African treatments involve purgation, as this is believed to purify the patient by cleansing the bowel. However, traditional herbal remedies vary enormously in strength and many such remedies are toxic if taken in overdose, for example isihlambezo. Community members should be made aware of the possible dangers of the overenthusiastic use of traditional purgatives. Caring for an incontinent person at home can be very difficult and distressing for both the patient and the carers. Such families need support from health workers, as well as practical advice on how to cope with the situation. Education could include advice regarding the use of various incontinence aids, as well as how to make simple incontinence aids at home if the family cannot afford to buy expensive incontinence pads and condom drainage systems. Advice about giving the client a receptacle for voiding or defecation at regular intervals can be useful as this serves as a type of bowel/bladder training and may reduce episodes of incontinence considerably. Many patients with chronic urinary incontinence can be taught intermittent selfcatheterisation. The patient is shown how to insert a Jacques catheter (one without a bulb) into the bladder at regular intervals to drain it, using all the necessary sterile precautions. As all individuals have a reasonably high degree of resistance to their own commensal organisms when in good health, the risk of urinary infections is considerably reduced if self-catheterisation is carried out. For patients being cared for at home, carers can also be taught how to carry out intermittent catheterisation to reduce the incidence of urinary retention and over-distension of the bladder.

Conclusion Elimination is a basic physiological need relevant for survival. Factors that influence elimination are found within the patient, such as age, fluid intake, activity, lifestyle and in the environment – that is, a clean and private toilet. Elimination is very much dependent on a pattern that is followed. For example, defecation may be related to the periods in the day – that is, in the morning or afternoon. It may be related to food – that is, before or after eating. For any form of elimination – urine or faeces – the patient needs privacy and to assume a natural position – that is, squatting for defecation and standing for males to pass urine. Nurses must assist their patients to meet this need, especially when they are in a strange environment.

Suggested activities for students Activity 23.1 Urinalysis is very important in the diagnosis of a patient. At this point, each student should correctly collect a urine specimen from him- or herself or a colleague, test it and analyse the results using the information provided in the text. The findings should then be recorded using the record form available in the institution where the practical is conducted. ➙

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Activity 23.2 For this activity, each student needs to collect a specimen of faeces from a patient with gastrointestinal problems in a medical or surgical ward. The specimen must be correctly labelled. The students should individually examine the stool specimens collected and discuss the results of their examinations.

Activity 23.3 Students should in groups of not less than five and not more than 15 (depending on class size) develop a health education guide in relation to elimination. In this guide, aspects covered should include the following: • Common problems of elimination (urine and faeces) • Nursing interventions in relation to the identified problems • Information on preventive measures.

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24

Comfort, rest and sleep need

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate competency in assessing factors that interfere with comfort, rest and sleep. • Plan for care that will promote comfort, rest and sleep.

Key concepts and terminology Analgesic: A drug that is taken to relieve pain. Apnoea: Inability to breathe. Deprivation: Denial of access. Hypnosis: An induced state of altered consciousness; can assist in diverting attention from pain or discomfort. Pain: A subjective response to discomfort and distress. Palliation: Treatment or act that serves to soothe. Relaxation: An act that promotes rest or recreation. Sleep: Can be described as a state of inhibited/suppressed consciousness from which a person can be aroused with appropriate sensory and other stimuli.

Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy and physiology • Basic nursing care.

Ethical considerations • Nurses are ethically obliged to provide an environment which is safe, pleasant and therapeutic, and which is conducive to rest and sleep. This function is one of the most basic attributes of nursing care. ➙

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• The sensation of pain is subjective, therefore individuals have different perceptions of and responses to pain. It is inappropriate and unethical for nurses to be judgemental or prejudiced when responding to their patients’ reactions to pain. • The National Patients’ Rights Charter states that patients have a right to a safe and healthy environment that promotes their mental and physical health and wellbeing.

Medico-legal considerations The maintenance of comfort, rest and sleep is elementary to nursing practice. The scope of practice for nurses authorises them to carry out interventions related to a variety of skills to fulfil these provisions, depending on their level of knowledge and expertise. The scope of practice protects the nurse and patient in the following: • The promotion of exercise, rest and sleep • The maintenance of hygiene, physical comfort and reassurance of the patient • The care of medications and the administration of medication to patients in the execution of a programme of treatment or medication prescribed for a patient by a registered person.

Essential health literacy Both patients and members of the general public should be made aware of the dangers of abusing sedative-hypnotic drugs.

Introduction Comfort, rest and sleep are aspects that are necessary to facilitate patient recovery, and the purpose of this chapter is to make nurses aware of their importance. Nurses will be assisted in developing an understanding of sleep and its functions, as well as measures to promote sleep and rest in their patients. The understanding of pain, its importance and functions, and measures to relieve pain and promote comfort will be discussed. Nurses are required to be proficient in the assessment of a patient who is experiencing pain and/or discomfort, or who is experiencing difficulty in sleeping. The degrees of comfort, rest and sleep can be used as indicators for good nursing care.

Sleep: its functions and importance Sleep, which takes up approximately 30% of our lives, is a basic physiological need and is essential for normal body function. Rest is integral to sleep.

Nursing implications Sleeplessness is an important symptom and should be assessed, reported and recorded, and the reason sought.

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How much sleep is necessary? The amount of sleep that individuals need differs. Babies sleep more than 12 hours per day, the elderly seldom sleep more than six hours per day, and the average adult sleeps between seven and eight hours per day. Epidemiological studies have indicated that adults who usually sleep more than nine hours or less than four hours per night have a higher mortality than those who sleep between seven and eight hours per night. Females on average sleep more than males, and both sexes sleep more during autumn than during spring. Whether adults really need eight hours of sleep is debatable. Researchers have found that those who sleep an average of fewer than six hours per day are probably better able to handle their daily activities than those who sleep for longer periods. Circadian rhythm The bodily functions of a human being follow a pattern over a 24-hour period, known as the circadian rhythm. It is almost as if the body has a biological stopwatch that controls its activities. Body temperature, pulse rate and blood pressure fluctuate throughout the day, and are usually lowest in the early morning hours (04h00 to 07h00). Circadian rhythms also differ among individuals. Some people are up and going as soon as they wake up, while others can only really start functioning at midmorning. This phenomenon is attributed to a point in the 24-hour cycle where an individual’s temperature falls to the lowest point. Should the person’s temperature fall to the lowest point late during the person’s sleep cycle, he or she will find it difficult to get up and to get going. Most people find that their reaction time is slower early in the morning than later in the day. With some individuals, peak efficiency is reached between 07h00 and 11h00 when the body temperature approaches its highest level. At this stage their metabolism is at its highest and they are at their most energetic. The pattern is found in all people, even among those working on night duty. Air travel may prolong or shorten one’s day while the body still functions according to its own biological clock, hence the phenomenon of jet lag. Travellers will need a period of a few hours or days to return to their normal sleeping, eating and working pattern. At birth, the sleep–wake cycle has not been developed yet – this only happens during the first three months. Hospitalisation has a great impact on this cycle because it disturbs a patient’s normal life pattern and routine. Sleep cycle There are two stages of sleep: 1. Slow-wave synchronised sleep or non-rapid eye movement (NREM) sleep 2. Desynchronised, dream, paradoxical or rapid eye movement (REM) sleep. First comes non-REM sleep, followed by a short period of REM sleep, and then the cycle starts over again. Dreams typically happen during REM sleep. REM sleep

During REM sleep, the eyes move quickly in different directions, which does not happen during NREM sleep. It is therefore a relatively active state and is referred to as

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paradoxical sleep. The sympathetic nervous system dominates during REM sleep. REM sleep restores a person’s ability to learn; it facilitates psychological adaptation and memory. Daily events are revised, processed and stored during REM sleep. Usually REM sleep occurs about 90 minutes after falling asleep and lasts about 10 minutes. Each later REM stage becomes longer, and the final stage may last an hour. Physiologically the individual’s heart rate and breathing quicken. Intense dreams may occur due to the brain being more active. Babies may have up to 50% of their sleep in the REM stage compared to only about 20% in adults. Commencement of REM sooner than 30 minutes after falling asleep is associated with sleep disturbances, such as narcolepsy or depression. NREM sleep

There are three phases of NREM sleep. Each phase can last 5–15 minutes, and all three phases are completed before entering REM sleep. • Phase 1: Eyes are closed but the person is easily arousable. This lasts 5–10 minutes. • Phase 2: Light sleep – the heart rate slows and the body temperature drops. The body gets ready for deep sleep. • Phase 3: Deep sleep – the person is harder to rouse, and if woken up, feels disorientated for a few minutes. During deep NREM sleep, the body repairs and regrows tissues, builds bone and muscle, and strengthens the immune system. With age the individual sleeps more often but the sleep is lighter and for shorter time spans. Table 24.1  Characteristics of sleep REM

NREM

• Active state • Intense dreams • Increase in heart rate and breathing • Increase in metabolic rate due to increased brain activity • Active rapid eye movement • Makes up 25% of sleep cycle • Difficult to arouse from sleep

• Passive state • Dreamless, peaceful state • Decrease in heart rate and breathing • Decrease in metabolic rate and temperature • No eye movement • Largest component of sleep cycle • Easy to arouse in first phase and becomes progressively more difficult

Physiological changes during sleep • Sleep does not recharge the energy consumed the previous day, because the duration of waking and sleep periods would then be the same. People who have not slept for a number of days usually sleep for less than a day before resuming normal activities. In contrast to this, sick people sleep much more than healthy persons do. Sleep deprivation results in the progressive dysfunction of the central nervous system with dysfunctional behaviour, irritation, anxiety, apathy, decreased concentration and decreased ability to think and/or remember. The primary function of sleep is therefore to restore the natural balance between centres in the brain. This activity 517

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•

•

•

•

• •

•

is the function of the autonomic nervous system, which regulates the activity of glands and involuntary smooth muscle in the walls of tubes, hollow organs and the heart. Basal metabolic rate decreases by 10–30% during NREM sleep. Even during REM sleep it is lower than during the wakeful state, although brain metabolism increases during REM sleep. Sleep therefore is an energy-saving state. Muscle tone decreases, especially during NREM sleep. The relaxing of skeletal muscle enables the body to channel energy to essential cellular activity, for example tissue repair. Sleep facilitates restoration, and decreases stress and anxiety, which enables the person to regain stamina for concentration, and interest in daily activities and the ability to handle them. Growth hormone is increased during sleep. Deprivation of NREM stage IV sleep decreases the release of growth hormone, making one feel tired, depressed and miserable. This hormone promotes tissue repair, and lack of sleep may be particularly detrimental to sick or injured patients. Breastfeeding mothers should ensure that they get enough sleep as the secretion of prolactin increases during sleep. Secretion of adrenocorticotrophic hormone (ACTH) decreases during NREM sleep. This hormone influences the adrenal cortex to secrete hormones such as cortisol aldosterone and corticosteroid during REM sleep. These hormones influence a person’s vitality, tiredness, metabolism, transmission of nerve impulses and resistance against infection. Deprivation of REM sleep may lead to adrenal hormones being released into the bloodstream at the wrong time, which will make a person feel depressed and tired, and suffer from poor concentration. A sufficient amount of NREM sleep is necessary to ensure enough rest and repair of the body. Waking patients up frequently will make them tired and negatively influence their ability to adjust to changes. Once awake, they will have to start the whole cycle from the beginning, and the chance that they will have sufficient sleep will become smaller.

Table 24.2  Stages of sleep Stage

Description

Pre-sleep period

Individual falling asleep feels relaxed and drowsy. Vital signs such as pulse rate and temperature start to drop. May experience jerking movements as the person moves into the first stage of sleep

NREM phase I Transition between being awake and sleep

Very light sleep. Vital signs drop further and muscles feel more relaxed. Perception of visual and auditory stimuli decreases. An individual may, however, react to stimuli without waking up. Slow, rolling movements of the eyes appear. Individuals can easily be woken up when in this stage. Duration is 5–10 minutes ➙

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Stage

Description

NREM phase 2 Commencement of sleep

This phase follows 15 minutes after starting to fall asleep if the person was not disturbed. Body functions diminish further and no eye movement is present, but the person can still be easily woken. Duration of this stage is 10–15 minutes

NREM phase 3

The person may move or talk during this stage. Further decline of bodily functions is seen as a result of parasympathetic nervous system domination. It becomes difficult to rouse the person

REM

Sleep during which dreams are experienced. These dreams promote psychological integration of daily activities. Vital signs fluctuate, heart rate and respiration are irregular, and the eyes move from side to side. There is increased relaxation of muscles, especially of the face and neck. Brain metabolism increases by 10–20%. Respiratory function decreases or may be irregular Respiratory muscles become hypotonic, and airway resistance increases. Cough reflex decreases. Adrenal hormones are secreted during this phase. The duration of this phase is 5–30 minutes

Factors that influence sleep and rest The following factors influence both the quantity and the quality of sleep: Illness

Disease increases the need to sleep and disturbs the normal sleep–wakefulness pattern. In illness there may be the following: • Pain may render sleep impossible or will wake the patient up. Patients with stomach ulcers often wake up at night as a result of the secretion of gastric juices during REM sleep. • Shortness of breath will make sleeping difficult. Patients must usually be propped up in bed with a number of pillows to lift the head and chest and to ease breathing. • A blocked nose and draining sinuses will hamper breathing and therefore also prevent a patient from sleeping. • Some diseases, such as liver failure and encephalitis, may cause reversal of day and night patterns. Hyperthyroidism may increase the pre-sleep period causing patients to find it difficult to fall asleep, and depression may increase or decrease sleep. • There is a strong relationship between the respiratory changes during REM sleep and the pathogenesis of obstructive sleep apnoea and cot death. Urinary excretion

A full bladder and the need to urinate will interrupt sleep, irrespective of whether it occurs as a result of disease or not. Once the patient has got up, he or she may find it difficult to fall asleep again. 519

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Environment

The environment can improve or inhibit sleep. Any deviation from the normal sleep environment at home may play a role. Persons used to the dark and the sound of traffic at night may not be able to sleep if it is too light or too quiet. New or unfamiliar sounds and environment may also disturb sleep. Temperature

The ability of the body to regulate temperature decreases during sleep and is totally absent during REM sleep. To prevent a sleep disturbance, one must therefore be appropriately covered to prevent being either too hot or too cold. Exercise

The influence of exercise differs among individuals. Exercise during the day up to two hours before bedtime improves sleep. Exercise nearer to bedtime may hamper sleep. A lack of sufficient exercise may make it difficult for some people to sleep. Emotional problems

Emotional problems and anxiety disturb sleep because the person cannot relax enough to fall asleep. Excessive stimulation – that is, more excitement than one is accustomed to – will make it harder to fall asleep for most people, unless they are exhausted by the stimulation. Medication

Sedatives and hypnotics – for example non-barbiturates such as sodiumtriclofos (Tricloryl syrup); benzodiazepines (Midazolam, Dormicum); nitrazepam (Mogadon); temazepam (Normison); and barbiturates such as phenobarbitone (Lethyl) – decrease REM sleep even though total sleep is increased. Amphetamines (central nervous system stimulants) and antidepressants (prescribed for the treatment of depression) cause an abnormal decrease in REM and NREM phase 3 sleep. Long-term use of amphetamines can cause abnormal behaviour as a result of REM sleep deprivation. Persons being withdrawn from these drugs get much more REM sleep than normal, wake up frequently through the night, and may suffer from bad dreams. These patients will therefore require a lot of support and reassurance from the nursing staff. Caffeine

Caffeine is found in coffee, tea, certain cold drinks and high concentrations are found in so-called energy drinks and ‘stay awake’ tablets. This substance stimulates the nervous system and causes diuresis, which can negatively influence sleep. Alcohol

Alcohol abuse disturbs REM sleep although it may hasten the start of sleep. As the effect of alcohol decreases, REM sleep periods increase and bad dreams may be experienced. Alcohol tolerance may be the cause of a lack of sleep, which leads to irritability. Nutrition

Loss of weight is associated with a decreased amount of total sleep, broken sleep periods and waking up early in the morning. In contrast, weight gain is associated with 520

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an increase of total sleep, decrease of broken periods of sleep and waking up later in the morning. L-tryptophan is an amino acid (building block of protein which is found in milk, cottage cheese, beef and canned tuna) that probably promotes sleep. This could explain why hot milk helps some people to fall asleep. A protein snack before bedtime can help to induce and maintain sleep.

Common sleep disorders • Insomnia. This is the inability to fall asleep or remain asleep. An individual with insomnia awakes feeling unrested. The incidence increases with age and is common in females, which may be related to hormonal changes. • Sleep apnoea. This occurs when an individual has more than five breathing pauses lasting longer than 10 seconds, and is characterised by loud snoring, frequent awakening, daytime sleepiness, memory and cognitive problems. Towards the end of each apnoeic episode, an increase in the carbon dioxide level in the blood causes the individual to wake up. There is a higher incidence in men but it affects postmenopausal women as well. • Hypersomnia. This occurs when the individual cannot stay awake during the day despite adequate sleep during the night. It is usually related to medical conditions such as diabetes, hypothyroidism and central nervous system damage. • Narcolepsy. This is excessive daytime sleeping caused by lack of the chemical hypocretin in the sleep-regulation centre of the brain. The individual has sleep attacks or excessive daytime sleepiness, but usually has sound night-time sleep. The incidence is more common among 15–30 year olds. Nursing interventions to promote sleep Support sleep patterns. Individuals have bedtime rituals or pre-sleep routines that help them relax and get comfortable. Include such activities or routines in preparing the patient for sleep. • Reduce environmental disturbances: –– Remove distractions such as noise, overhead lighting and poor ventilation. –– Close the curtains or door to ensure privacy. –– Ensure safe environment with, for example, the cot sides up, the call bell at hand, and the night light and bed in lowest position. –– Limit activities or ensure that all nursing activities are completed before bedtime to reduce sleep interruptions. –– Noise from staff communication, the use of equipment, the telephone ringing and staff walking around should be kept to a minimum so that this does not interrupt sleep. • Promote comfort and relaxation: –– Ensure that the bed is clean and the linen smooth. –– Encourage the patient to wear loose-fitting, comfortable nightwear. –– Assist the patient with bedtime rituals. –– Ensure that the patient voids prior to settling down to sleep. –– Position the patient for comfort. –– Ensure that the room temperature is comfortable for the patient and that adequate linen is provided. 521

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–– Teach relaxation techniques such as deep breathing, rhythmic contraction and relaxation of muscles, imagery or listening to soft music. • Provide medication to enhance sleep: –– Sedative-hypnotics may be prescribed to enhance sleep. –– Anti-anxiety drugs may also be prescribed for anxiety or stress. –– The medication should be administered only after a full patient assessment is done and there are no contraindications noted. –– The patient must be monitored regularly to ensure that there are no adverse effects from the drugs.

Pain: its functions and importance Pain is a subjective response to discomfort and distress impacting negatively on rest and sleep.

Specific objectives • Assess pain and discomfort, both subjectively and objectively. This implies recognition of the physical signs and symptoms that accompany pain and discomfort, as well as the patient’s subjective reporting of how he or she is feeling. • Implement nursing interventions designed to promote comfort, rest and sleep in a patient, such as the appropriate use of non-pharmacological and pharmacological measures to relieve pain. • Monitor the patient’s response to analgesic medication, including observing the patient for signs of overdose.

Nursing implications • Pain is always a significant symptom, and nurses must always ensure that the relevant doctor is made aware of a complaint of pain, especially if this is a new occurrence. Nurses should report the location, character, onset and duration of the pain. • Nurses must ensure that the legal requirements relating to the administration of medications are met. These include a clear prescription, checking of the medication with a responsible colleague before administering it to the patient, and keeping clear and accurate records of the administration of medicines or drugs. • Nurses must ensure that the drug registers, order books and patient files are completed and up to date, and checked at regular intervals. • Nurses must always ensure that the drug cupboard keys are kept safe. All patients who have had sedation or a strong analgesic should be nursed in a cot bed with the sides raised. These agents cause drowsiness, and may cause mental confusion, especially in elderly patients. A confused patient may easily fall out of bed.

Physiology of pain Pain is usually an important sign that something is physiologically wrong. Pain receptors differ from the other sense organs in that they do not adapt to continuous stimulation, such as occurs with the other sense organs. Most people have probably had the experience of no longer being aware of the presence of a particular sound 522

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until there is sudden silence. A sound stimulus continued over a period of time no longer excites the receptor. The non-adaptability of the pain receptors provides a very important aspect of the body’s protective mechanism. It is protective in that the pain fibres are indefatigable in transmitting stimuli warnings that tissue damage, or potential damage, is in progress. The principal pain receptors, called nociceptors, are the several million bare sensory nerve endings found chiefly in the skin, muscles, joints, tendons, dura mater, periosteum and arterial walls, and to a lesser extent in the viscera, and which respond to a variety of noxious stimuli. The nociceptor is either stimulated directly by damage to the receptor cell or secondarily by the release of chemicals such as bradykinin, histamine, prostaglandins, acids and potassium ions from the damaged tissues. Pain fibres from the nociceptors enter the spinal cord through the dorsal roots in the spinal column and travel to the substantia gelatinosa in the dorsal horn of the grey matter. The impulses cross to the opposite side of the cord and travel via the spinothalamic tracts in the spinal cord to the reticular formation of the medulla, pons and mesencephalon in the brain. These impulses activate the reticular system in the brain and this alerts the person to the pain and motivates him or her to take steps in response. Three types of stimuli excite corresponding types of nociceptors, as indicated in Table 24.3. Table 24.3  Types of pain stimuli Stimulus type Mechanical • Trauma to body tissues (eg surgery) • Alterations in body tissues (eg oedema) • Blockage of a duct • Tumour • Muscle spasm Thermal • Extreme heat or cold (eg burns) Chemical • Tissue ischaemia (eg blocked coronary artery) • Muscle spasm

Physiological basis Tissue damage: direct irritation of the pain receptors; inflammation Pressure on pain receptors Distension of the lumen of the duct Pressure on pain receptors; irritation of nerve endings Stimulation of pain receptors (also see Chemical). Tissue destruction; stimulation of thermosensitive pain receptors Stimulation of pain receptors because of accumulated lactic acid (and possibly other chemicals, such as bradykinin) in tissues

Types of pain Types of pain may be described by the following: • Onset of occurrence – post-operative pain • Duration or length of time – acute or chronic pain

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Cerebrum

Cerebral cortex

Corpus callosum Thalamus

Hypothalamus Pituitary gland Pons

Reticular activating system

Cerebellum

Medulla

Figure 24.1  Reticular activating system of the brain • Intensity of pain – severe or mild pain • Mode of transmission – projected or referred pain (eg a patient with gall stones may experience pain in the region of the scapulae in the upper back) • Manner in which pain is experienced – sharp/burning/throbbing • Location or source – pain extends to surrounding tissues (eg cardiac pain that extends to the left shoulder and arm) • Phantom pain – pain felt in a body part that is no longer present (eg amputated leg) (Phantom sensation is a feeling that a missing part is still present, which probably results from stimulation of a severed dendrite.) • Intractable pain – resistant to cure or relief (eg the pain of arthritis). Clinically, pain is classified as somatic or visceral: • Somatic pain, arising from the skin, muscles or joints, can be either superficial or deep: –– Superficial somatic pain is a sharp, pricking pain that often causes a person to cry out. It is localised in the epidermis of the skin or in the mucosa, and tends to be sharp and brief. –– Deep somatic pain is more likely to be a burning or aching pain. It results from stimulation of pain receptors in the deep skin layers, muscles or joints. Deep somatic pain is both more diffuse and longer lasting than superficial somatic pain, and it always indicates tissue destruction. • Visceral pain results from noxious stimulation of receptors in the organs of the thorax and abdominal cavity. Like deep somatic pain, it is usually a dull ache, a burning feeling or a gnawing pain. The most important stimuli for visceral pain are extreme stretching of tissue, ischaemia, irritating chemicals and muscle spasms. Because visceral pain inputs follow the same pathways as somatic pain, projection by the brain may cause visceral pain to be perceived as somatic in origin.

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Response of the body to pain Stages of pain

The response of the body to pain is a complex process, which can be separated into three stages: • Stage 1: Activation stage. This stage begins with the perception of pain. The body assumes a flight-or-fight reaction, initiated by the sympathetic nervous system. This includes pallor, elevated blood pressure, dilated pupils, skeletal muscular tension, and increased respiration and heart rate. • Stage 2: Rebound stage. This is the stage when the parasympathetic nervous system takes over. The pain experienced is intense but brief, and cardiac rate and blood pressure decrease. • Stage 3: Adaptation stage. In this stage the sympathetic response is decreased. This occurs with long-lasting pain. Adaptation may be due to endorphins counteracting the pain. Emotional response

Changes in body chemistry due to pain can influence a person’s behaviour. Secretion of excessive norepinephrine makes the individual feel powerful, in control, confident and excited. When norepinephrine is depleted (eg with prolonged pain), the individual may feel helpless, worthless and lethargic. The production of serotonin is increased by the stimulation of the inhibitory system that counteracts pain. This reaction can be seen in persons after they have meditated or taken narcotics – they feel serene, secure and safe. Depleted serotonin levels – as seen with chronic pain – produce tension, agitation, anxiety, hypersensitivity and a variety of sleep disorders. Persons with depleted norepinephrine and serotonin may demonstrate agitated depression and may be unable to cope with pain, irrespective of its severity. Pain threshold

All people have the same threshold for pain, which means that pain is perceived at the same stimulus intensity. For example, heat is perceived as painful at 44–46°C, the range at which it begins to damage tissue. Pain threshold is therefore the minimum amount of stimuli a person requires in order to acknowledge it as a sensation of pain. Pain tolerance

Reaction to pain or pain tolerance varies widely from person to person, and is heavily influenced by cultural and psychological factors. If someone is ‘very sensitive to pain’, this refers to the person’s pain tolerance rather than pain threshold. Pain tolerance is therefore the maximum amount of stimuli the person can withstand before seeking relief of the pain.

Factors influencing the perception of pain Many psychosocial factors can influence an individual’s perception of pain: • Family expectations. The role a person plays in the family will influence a person’s response to pain. For example, a single mother supporting three children may ignore pain due to her need to keep her job. Support persons, such as parents or nurses, may make toddlers able to tolerate pain more readily. ➙

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• Environment. A person may perceive pain as more severe and also react more openly when lying in hospital than at home with the family or entertaining friends or co-workers. • Emotions. A person participating in sport may be totally unaware of the pain of an injury until after the game is over. A bored or depressed person, in contrast, will be more likely to think about his or her pain and therefore be more aware of it. Anxiety also heightens the perception of pain. • Culture. The meaning of pain varies between cultures. Nurses will therefore observe a variety of responses to pain, none of which should be judged as good or bad. For example the Chinese respond stoically to pain while the Italians tend to react more expressively. The important factor is always to be on the lookout for non-verbal clues during assessment of a patient. • Other factors. Factors such as fatigue and fear may augment pain.

Nursing assessment of comfort, rest and sleep Causes of discomfort A person’s comfort can be adversely affected by sensations of physical distress or pain and also by dissatisfaction related to the individual’s psychological or physiological comfort. Discomfort and pain may be associated with the existent pathology and the bodily reactions to it and the psychological stresses associated with hospital admission. Physical conditions causing discomfort that may be encountered by a sick person include nausea and vomiting, distended bladder or bowel, hunger, thirst, coughing, vertigo, headache, muscle tension or pain. Discomfort may result from the tension of continued unsatisfied needs. External sources of discomfort can include many factors, for example: • Personal hygiene needs. A dry, coated oral mucous membrane of the mouth causes a lot of discomfort and presents a source of possible infection. A weary, restless, perspiring patient with crumpled, soiled bed linen will experience improved comfort levels from a bed bath and a change of bed linen. • Uncomfortable position. Improper positioning of the body and/or limbs may cause muscle and joint discomfort. • Pressure. Pressure from casts, bandages, blankets and other devices may cause considerable pain to a patient and may even be dangerous, as such pressure can lead to pressure sores, or even loss of blood supply and gangrene. • Environmental factors. A great many environmental factors may be experienced as disturbing by a patient, such as noise, lights, ventilation, disturbing sights or the behaviour of other patients. These factors contribute to irritability, restlessness and emotional tension.

Assessment of discomfort An individual may be aware of the source of discomfort and may be able to communicate with the nurse about it if encouraged to report and discuss physical needs with the nurse. If hospitalised and unable to report needs, the patient is totally dependent on the nurse for assessment and intervention. 526

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To assess a person’s status with regard to comfort, rest and sleep, the nurse needs information about the person’s usual sleep and rest patterns, any sleep problems he or she may have (eg insomnia), as well as the nature of his or her current health problem that may be causing discomfort. In addition to this, the nurse needs to know whether any restrictions were placed on the patient’s mobility and what treatment his or her doctor prescribed. Most of this information should be obtainable from the nursing history and the initial assessment of the patient. This information is supplemented by the nurse’s objective observations. Complete information about the patient’s discomfort should be gathered as accurately as possible and evaluated in relation to significant factors such as the patient’s age, general physical condition, diagnosis and its commonly associated problems, emotional status, and attitude towards illness. Any new, severe or sudden pain and discomfort not readily relieved by nursing measures should be recorded as such and reported promptly. Sensory deprivation – such as room isolation, one or more eye patches, lack of room light, social isolation, restriction of movement and inactivity – frequently increases awareness of what might otherwise be considered as minor discomforts. The following findings may indicate discomfort: • Restlessness, tossing and turning in bed, sighing, tenseness or muscular rigidity, which can be related to many factors (eg pain or a full bladder) • Space and place disturbance, which is recognisable by overzealous protection of ‘established territory’ (bed, bedside table, belongings) • Irritability or difficulty in the patient. Disturbed sleep patterns as evidenced by easy arousal and awakening may also be indicative of discomfort.

Facilitating comfort When the nature of a patient’s discomfort has been identified and evaluated, the nurse may intervene appropriately to relieve or minimise it and try to prevent complications. Whatever is done for the patient should be planned with the patient whenever possible. Knowledge of what is to be done and why provides a feeling of some control over the situation, and helps to restore a feeling of ease and comfort that may have been disrupted by the illness situation. A feeling of psychological comfort and safety will enhance other measures to promote comfort. A feeling of safety and security can be achieved in an individual by the following: • Increasing knowledge about a situation before it occurs • Physical care ministrations that can be used to develop a trusting relationship • Supportive relationships with others to whom the patient may verbalise about the situation • The experience of approval and acceptance by the significant others in the situation • The ability to communicate needs to a trusted person in the situation. Specific interventions to promote comfort could include the following: • Promote relaxation – learning the skill of progressive relaxation can assist a person to reduce tension in his or her breathing, neck, shoulders, abdomen, legs and other muscles. 527

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• Minimise or avoid factors that increase tension; this will also promote relaxation. • Identify and fulfil all unmet basic needs, for example hunger, thirst, excretion, emotional and hygiene needs. A bed bath and mouth care for a bedridden person will contribute immensely to his or her comfort. • Always ensure that the person who is in your care is comfortable, whether he or she is lying in bed or sitting in a chair. Ensure correct body alignment, regular massage of pressure parts and a clean, neat and wrinkle-free bed. • Promote sufficient rest and sleep.

Assessment of pain A full history and assessment of a patient is necessary for successful pain management. Reasons for this are the following: • Body weight and other physical factors may influence the treatment of pain. • The presence of other diseases such as kidney or liver disease will influence the type and dosage of any drugs to be administered. Patients with debilitating diseases, whether old or young, have a heightened sensitivity to the effects of narcotics. Defining the cause of the pain will be valuable in that this enables the health professional to choose the treatment according to the different responses to pain. For example, chronic bone pain may respond dramatically to radiation treatment, and if drug therapy is necessary, the addition of a non-steroidal anti-inflammatory drug is usually indicated. In contrast, a patient with chronic pain due to nerve injury with the development of a traumatic neuroma will probably require some form of interventional treatment such as surgery.

Clinical signs and symptoms of pain The subjective data are obtained by taking a pain history. Objective data can be obtained by observing the behavioural responses by a patient, such as the following: • Facial expression (eg clenched teeth, biting the lower lip, tightly shut eyes) • Purposeful body movements (eg immobilising the painful body part, flexing the knees and hips when experiencing abdominal pain) • Purposeless body movements (eg flinging arms about, tossing and turning) • Rhythmic body movements (eg rubbing, tapping, massaging) • Changes in speech (eg rapid speech and elevated pitch may indicate anxiety; slow speech and monotonous tone can signal intense pain) • Associated symptoms (eg vomiting, dizziness, constipation). Table 24.4  Responses to pain Sympatho-adrenal

Parasympathetic

Neuro-muscular

Emotional

responses

responses

responses

responses

• Increased pulse rate • Increased systolic blood pressure

• Decreased blood pressure • Decreased heart rate

• Possible loss of consciousness and muscle tone

• Behavioural change such as: –– irritability  ➙

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Sympatho-adrenal

Parasympathetic

Neuro-muscular

Emotional

responses

responses

responses

responses

• Increased respiratory rate • Excessive perspiration • Nausea and vomiting • Contraction of striated muscles • Pallor • Bronchial dilation • Conversion of stored glycogen to glucose • Release of erythrocytes from the spleen • Pupil dilation

• Nausea and vomiting • Pallor • Weakness and fainting • Prostration

–– extreme quietness –– groaning –– crying –– increased alertness

Pain rating scales The examples in Figures 24.2 and 24.3 can be used to ask a patient to indicate the intensity of the present pain. These scales can be used as often as desired: 1. An adult patient can be asked to rate his or her pain on a scale of 1–10.

0     1      2      3      4      5     6      7      8      9     10 No pain

Moderate pain

Worst possible pain

Figure 24.2  Numbered rating scale 2. A patient can be asked to indicate how he or she is feeling using the happy/sad faces rating scale. The Wong-Baker Faces® Pain Rating Scale can be used for any person older than three. Explain to the patient that each face represents a person who feels happy because he or she has no pain, or sad because he or she has a little or a lot of pain. Face 1 is very happy because he or she has no pain at all. Face 2 hurts just a little bit. Face 3 hurts a little more. Face 4 hurts even more. Face 5 hurts a lot. Face 6 hurts as much as you can imagine, although you do not have to be crying to feel as bad as this. Ask the person to choose the face that best describes how he or she is feeling.

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1            2     

3    

  4    

  5   

   6

Figure 24.3  Wong-Baker Faces® Pain Rating Scale used with permission

How to approach a patient when assessing pain Never ask leading questions, or questions that suggest the answer that the nurse is looking for. Instead of asking if the patient has pain, the nurse should ask how he or she is feeling. If the patient is experiencing pain, he or she will certainly inform the nurse of this fact. Alternatively, the nurse can ask the patient to describe his or her symptoms. Again, if the patient is feeling pain, he or she will certainly inform the nurse of this symptom. If analgesia was given prior to the assessment, the nurse can ask how the patient is feeling now. Once it has been established whether the patient is experiencing pain or not, the nurse can ask the patient to rate the pain, or lack of it, on a rating scale.

Patients who cannot communicate Patients who cannot tell you about the nature and severity of their pain present a great challenge. A patient’s self-report is always the best indicator of the existence of pain, but for those who cannot speak or point to a scale, the nurse needs to look for other indicators of pain, such as behavioural and physiological responses. When assessing patients who cannot communicate the presence of pain, first consider all of the factors that can result in discomfort. Check the patient’s diagnosis. For example, if a patient’s condition usually results in pain, the nurse should anticipate the need to intervene appropriately. Conditions such as tumour growth, pneumonia, arthritis and pressure ulcers can be very painful. Surgical procedures such as chest, abdominal or major orthopaedic procedures certainly result in pain and need intervention. The best way to manage such patients is to request that a physician select an around-the-clock schedule for pain medication. It is also important to check the patient’s position in the bed, and to see if any device, intravenous lines or linen may be causing the discomfort. Relief of pain Specific therapy should, whenever possible, be directed at the cause of pain. Ancillary problems that aggravate pain (eg coughing, anorexia, diarrhoea and constipation) need to be treated as well. 530

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Palliation or pure symptom control measures may be used in the following situations: • If the primary cause of pain cannot be treated or removed • As a temporary measure until the primary cause can be found • To supplement other therapeutic measures. The usual clinical practice for controlling pain is to give analgesic medications along with other supplementary medications or therapeutic measures, for example rest and a proper position. As emotion and social situations affect the experience of pain, the concept of total pain has become an important factor in pain management. This means that physical, emotional and psychological aspects of pain must be addressed simultaneously and should therefore ideally involve a multidisciplinary team. Postoperative pain is the most common form of acute pain and is often not adequately treated. Adequate post-operative analgesia produces a more mentally alert patient who can effectively cough, breathe and move around, and therefore lower the incidence of respiratory complications and deep-vein thrombosis as well as pulmonary embolism. Severe chronic pain is a problem in its own right and can be more debilitating and intolerable than the disease process or injury that initiated it. Such pain imposes severe emotional, physical, economic and social stress on the patient and his or her family, and is one of the most costly health problems for society. People suffering from chronic pain should be assessed and a treatment programme planned by a multidisciplinary panel.

General measures to relieve pain and promote comfort Plan general nursing care measures to relieve pain in conjunction with a careful assessment to determine if analgesics are needed. Measures that must be kept in mind are the following: • Correct alignment and positioning in bed – for example, by correctly positioning the patient’s leg in a cast, pain may be relieved to such an extent that no analgesic is required. The muscles surrounding painful inflamed or injured tissues should be supported in such a way so as to ensure the complete relaxation of these muscles. • Massage is most useful in the early stage of inflammatory swellings and in treating the pain of various forms of myalgia, fibrositis or labour. Effective massage, however, can be a useful adjunct to other pain-relief measures, and may lessen the need for drugs. The nurse must protect the patient from pain-producing stimuli such as distension of hollow visceral organs (full bowel/bladder) or further damage to traumatised tissue. • Injured tissue should be handled carefully. • Painful procedures should be done at a time when pain-relieving medications are having their maximum effect. In fact, analgesic doses should be planned so that the dose can be given prior to a painful procedure or dressing. • Drainage tubes should be checked frequently to ensure that they are not caught, stretched, pulled, kinked or looped, and that they are positioned correctly to enhance drainage and reduce distension and pressure. • Care must be taken to prevent fatigue. Overtiredness decreases pain tolerance. • Immobilisation may reduce pain caused by inflammation or the interruption of blood supply. • Elevation may relieve pain in swollen body parts. 531

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• A position of semi-flexion may reduce the pain of joint disorders. • The pain of muscle spasm may be relieved by a change in position. • Frequent position changes along with a good body alignment may prevent painful muscle contractures. • Any unmet needs that may be contributing to a patient’s pain should be identified. If a patient’s basic needs are met, pain or discomfort may be reduced or even eliminated.

Behavioural techniques The intensity of pain can be reduced by various behavioural techniques, as described below. Distraction techniques

Distraction draws the person’s attention away from the pain, lessens the perception of pain and makes a person less aware or even unaware of pain. For example, injuries are frequently only felt after a ballgame is over. Similarly, a patient recovering from surgery may feel no pain while watching rugby on television, yet feel pain again when the game is over. The effectiveness of distraction is based on the ‘gate control’ theory. The receptor cells in the spinal cord receiving the peripheral pain stimuli are inhibited by stimuli from other peripheral nerve fibres carrying different stimuli. Because pain messages travel more slowly than other stimuli, the other stimuli enjoy priority and arrive at the brain first. This phenomenon is described in terms of a pain gate, which can be opened or closed, depending on the number and type of stimuli arriving at the spinal cord. When numerous other stimuli are arriving, the ‘pain gate’ is said to close, fewer pain stimuli are transmitted to the brain, and the patient feels less pain. Unpleasant distractions (loud noises or odours, bright light or unwelcome visitors) may, however, increase pain perception because of the unpleasant feelings associated with them. The nurse needs to reduce such stimuli. Distraction techniques include the following: • Slow, rhythmic breathing. Instruct the patient to stare at an object and inhale slowly through the nose while counting from one to four, and then exhale slowly through the mouth while counting from one to four again. Encourage the patient to concentrate on the sensation of breathing and to picture a restful scene. Continue until a rhythmic pattern is established. • Massage with slow, rhythmic breathing. Instruct the patient to breathe rhythmically and at the same time massage the patient’s painful body part with stroking or circular movements. • Rhythmic singing and tapping. Ask the patient to select a well-liked song and concentrate attention on its words and rhythm. Encourage the patient to mimic the words and tap a finger or foot. Loud, fast songs are best for intense pain. • Active listening. Have the patient listen to music and concentrate on the rhythm by tapping a finger or foot. • Guided imagery. Ask the patient to close his or her eyes and then imagine and describe something pleasurable. As he or she describes the image, ask about the sights, sounds and smells imagined, encouraging the patient to provide details.

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• Cutaneous stimulation. This is a refinement of distraction in which tactile stimulation is used to distract the patient from his or her pain. –– Heat (hot water bottle, hot pads and ultrasound) and cold (ice packs) applications can be used for pain relief. Heat stimulates serotonin production; cold stimulates norepinephrine production. –– Cold packs slow the conduction of pain impulses to the brain and motor impulses to muscles in the painful area, and provide quicker and longer-lasting pain relief than hot packs. Cold packs help to relieve headaches, muscle strains, joint pain, and muscle spasm and back pain during childbirth. –– Analgesic ointments containing menthol relieve pain, but the analgesic mechanism is unknown. These ointments produce immediate sensations of warmth that last for several hours, and even longer if the body part is wrapped in plastic. They can be used to relieve joint or muscle pain. Menthol ointment rubbed into the neck, scalp or forehead sometimes relieves tension headaches. –– Counter-irritants, such as mustard plasters and liniments, may be used to relieve the aching joint pain of rheumatoid arthritis and osteoarthritis. Counter-irritants are thought to relieve pain by increasing circulation to the painful area. –– Contralateral stimulation involves stimulating the same part in the opposite side of the body, for example stimulating the left knee if the pain is in the right knee. The contralateral area may be scratched for itching, massaged for cramps, or treated with cold packs or analgesic ointments. This method is particularly useful when the painful area cannot be touched because it is hypersensitive or inaccessible because of a cast or bandages. • Relaxation. This is a specific form of distraction that is very effective for chronic pain and for persons subjected to other forms of stress. Relaxation techniques reduce anxiety or stress, ease the pain of muscle tension, disassociate a person from pain, help the person to obtain maximum benefits from sleep and rest periods, enhance the effect of other pain therapies and relieve the hopelessness and depression associated with pain. Women in labour are an excellent example of a situation where relaxation and breathing have been used for many years to lessen pain.

The requisites to relaxation are correct posture, a mind at rest and a quiet environment. The person should be positioned comfortably with all body parts supported and joints slightly flexed with no strain or pull on muscles such as crossed arms or legs.

Several relaxation methods have been described. An easy one is to first tense separate muscle groups (eg neck, shoulder, back, arms and legs) and then relax them. After all muscle groups have been done, the whole body is tensed and then relaxed. This can be repeated a few times, after which the person should be relaxed and can then concentrate on slow rhythmic breathing.

Drug therapy

Principles of analgesic administration • The dosing interval should be worked out so that the next dose is given before the pain has become too severe. ➙

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• If a patient seems to be requiring more analgesia than what is prescribed, consult with the patient’s medical practitioner. Do not make the patient wait for analgesia simply because it is ‘not time for the next dose’, but rather consult with the medical practitioner as soon as possible. • Some medical practitioners prescribe a regular dose of analgesia – that is, the dose is not p.r.n. In this case, the dose must be given at the prescribed intervals and not omitted, even if the patient does not seem to require it. • Concern over possible addiction is widespread among nurses, and this concern is inappropriate. When opioids are used for pain relief, the incidence of permanent addiction is minimal. It is better for a patient to be comfortable and free of pain than to be kept waiting for a needed dose of analgesia because of an overzealous nurse’s concern over addiction. Some patients do become dependent, especially if they need to receive analgesia over an extended period of time, but this dependence is easily treated by gradually reducing the dose, lengthening the dosing interval, and finally weaning the patient onto milder, non-addictive analgesics. • Always remember that the relief of pain is one of the key functions of the nurse, and one that is perceived by the community as being characteristic of good nursing and therefore particularly important. Analgesics alter the perception and interpretation of pain by depressing the central nervous system at the level of the thalamus and the cerebral cortex. Analgesics are more effective when given before the patient feels severe pain than after the pain has become severe. For this reason, analgesics are given at regular intervals. Opioids

Opioids relieve pain by binding to opiate receptors and thereby activating endogenous pain suppression in the central nervous system. Changes in mood and attitude, and feelings of wellbeing make the person feel more comfortable even though the pain may persist. Pure agonists, such as morphine, pethidine, papaveretum (Omnopon) and codeine; and agonist-antagonists, such as pentasocine (Sosegon), buprenorphine (Temgesic) and nulbuphine (Neubain) are examples of drugs used for pain management. In order to achieve an acceptable level of analgesia, relatively constant plasma opioid concentrations must be rapidly achieved and then maintained. The route of administration plays an important role.

Patient-controlled analgesia (PCA) • In suitable patients, PCA is a very valuable and rational way to meet the patient’s need for pain relief. To be eligible for PCA, the patient must be conscious and able to understand how to use the device. • An intravenous preparation of a suitable opioid analgesic is mixed in a syringe to a strength of 1 mg/ml. • The strength of the dose and the waiting period before the next dose (lockout period) are pre-set, usually by the medical practitioner. ➙

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• The patient is then able to administer doses of analgesia by means of a hand-held pump. Although some of the patient’s pumping actions may not always result in the delivery of a dose due to the lockout period, the patient has the comfort of feeling in control of his or her own pain-relief medication. Non-steroidal anti-inflammatory drugs (NSAIDs) and simple analgesics

Non-narcotic analgesics include non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and acetaminophen. Non-narcotic analgesics relieve pain by acting on peripheral nerve endings at the injury site and interfering with the prostaglandin system. In many types of pain, particularly the pain of inflammation, it is the production of prostaglandins that causes pain by irritation of the nerve endings. In addition, several combinations of narcotic and non-narcotic analgesic drugs are available, such as Tylenol. NSAIDs are often combined with simple analgesics such as paracetamol after minor peripheral surgery and are very valuable in combination with opioids after major surgical procedures, as they can be used to enhance and prolong the analgesic effect of the narcotic. NSAIDs are very effective for incisional pain, and bone and postthoracotomy pain, but should be used for as short a time as possible because of the risk of side effects. Local anaesthetics

These can be administered topically, by infiltration, or via nerve blocks, plexus blocks or spinal/epidural routes. Currently, post-operative opioids are combined with local anaesthetics in the form of regional or epidural blocks.

Radiation therapy Palliative radiation therapy (and/or chemotherapy) will usually be considered in cancer patients with bone metastases, spinal cord compression, bleeding or painful skin and mucosal lesions, masses that cause pressure or obstruction, cerebral metastases and pain in organs (eg pancreas, liver or stomach), which does not respond to the traditional treatment modalities. Radiation therapy can also be used for benign conditions, for example peptic ulcers, or arthritis in selected cases. Radiation therapy must, however, be such that it provides increased physical wellbeing and does not increase the patient’s discomfort and actually add to the suffering. Other supportive therapies Supportive therapy, particularly in cases of chronic pain, may consist of one or more of the following: • Counselling in groups or as an individual can be offered. • Stress management courses can help patients. • Assertiveness training is another option. • Hypnosis has been used to treat psychogenic pain, to achieve anaesthesia and to enhance the effectiveness of medication given for pain aggravated by tension. The susceptible person accepts positive suggestions, which tend to alter perceptions. The success of hypnosis depends to a large degree on the person’s openness to suggestion, emotional readiness and faith in its effectiveness. 535

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• Physiotherapy, among other things, prevents post-operative complications as well as muscle contractions, and can be used to teach a patient to use an artificial limb. • Occupational therapy can, for example, provide a patient with distraction activities. • Dietary management will help a patient adapt to his or her condition, and prevent complications such as constipation.

Facilitating rest and sleep The following are some of the nursing interventions that nurses have found to be helpful in making a patient comfortable and promoting rest and sleep: • A warm bath before bedtime aids relaxation. • Make sure the patient is in a comfortable position in bed, especially if that person cannot move. • Duplicate the person’s usual night-time rituals as much as possible. For example, a child may sleep with a teddy bear. • Ensure sufficient diversional activities throughout the day, if the person’s condition permits, to prevent too much sleep during the day. Morning naps are considered more beneficial than afternoon naps, as they are a continuation of the light REM sleep, whereas if a person sleeps in the afternoon, it is often a heavy deep sleep from which he or she awakens feeling groggy. • If hypnotic drugs have been ordered, they should be given a few minutes before the lights are turned off. Analgesics to relieve pain should be administered sufficiently early for them to take effect before the hypnotic is given as this enhances the effect. • Advise the patient to avoid tea and coffee before bedtime, as both are stimulants. Warm milk or a glass of wine has been found to act as a mild sedative in inducing sleep. Snacks, especially if a patient is used to them, may be helpful. • Provide for quiet and darkness. • Limit noise and other external stimuli.

Essential health promotion and health education • Persons caring for patients in the community need to be educated in all of the techniques of promoting comfort, including the use and administration of analgesic medications. Of particular benefit in a home-care situation are the ancillary techniques for pain relief, such as relaxation, distraction and cutaneous therapies. If narcotic analgesics are being used, carers need to know how to give them, what the side effects are and how to deal with them. • Pain is an important symptom and one that should never be ignored. Specific types of pain, such as chest pain, abdominal pain and even the humble headache, can have a particular clinical significance, and the community needs to know what sort of pain can safely be ignored or handled with an aspirin, and which requires treatment.

Conclusion In this chapter patient comfort, sleep and rest were discussed in terms of the nurse being able to assess the patient and plan relevant nursing care. The importance of adequate 536

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and appropriate assessment of patient comfort is vital in order to provide nursing care that helps alleviate the patient’s discomfort. Pain is one of the main causes of patient discomfort therefore the assessment and management of pain was discussed. Most patients have difficulty sleeping of which pain may be a cause; however there could be various other reasons for the patient not being able to sleep and rest adequately. Therefore the nurse must understand sleep, the causes of sleeplessness and how to promote patient sleep. The degree of patient comfort, rest and sleep is a good indicator of quality nursing care.

Suggested activities for students Activity 24.1 Sleep promotes rest, which is important for the body to recuperate. • Analyse the possible sleep pattern of a rural housewife admitted into a surgical ward after corrective surgery following a fractured femur sustained in a motor vehicle accident on the highway. The woman was a pedestrian.

Activity 24.2 Pain, although distressing, is necessary. Do you agree or disagree with this? Debate this statement.

Activity 24.3 Rest and sleep are an indication of comfort. Do you agree or disagree with this statement? Provide reasons to support your answer.

Activity 24.4 Review the National Patients’ Rights Charter and identify which right/s cover the comfort, rest and sleep of an individual.

Activity 24.5 Review the scope of practice of a nurse and describe your responsibilities related to comfort, rest and sleep in the nurse category you are studying towards (eg staff nurse).

Activity 24.6 Browse the sleep and health journal site: http://www.sleepandhealth.com/ and note the latest research on sleep and sleep patterns.

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chapter

25

Skin integrity need

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate competency in assessing the condition of skin. • Identify the type of wound and skin lesions. • Plan and implement appropriate nursing interventions to prevent and maintain skin integrity and promote wound healing.

Key concepts and terminology Contractures: Scar formation as a result of healing following tissue injury. Cyanosis: Blue colour of the skin as a result of poor oxygen in the circulating blood. Dehiscence: A complication that happens during wound healing where the wound breaks down due to infection or other structural factors such as obesity, sometimes to the extent that underlying structures are exposed. Interstitium: Tissue in between cells. Keratin: Micronutrients found in carrots that are beneficial for sight. Melanin: Dark pigmentation. Melanocytes: Brown pigment cells that contribute dark colour to hair. Necrotic tissue: Dead tissue due to infection. Neutrophils: A type of white blood cell. Pruritis: Medical term for itchiness. Sebum: An oily secretion by the sebaceous glands, the function of which is to soften and lubricate skin and hair. Striae: Stretch marks. Urticaria: Skin lesion characterised by itchy weals or raised bumps, usually caused by an allergic reaction to certain substances such as food, skin applications or even medication.

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Prerequisite knowledge The nurse should have knowledge of the following: • Anatomy and physiology of the skin • Microbiology and parasitology • First aid.

Medico-legal considerations The scope of practice of registered nurses authorises them to carry out the following relating to the maintenance of skin integrity: • The facilitation of the healing of wounds • The protection of the skin • The prevention of bodily deformities as a result of wound healing. Nurses may use a variety of skills to fulfil these provisions, depending on their level of knowledge and expertise. These could include the following: • Aseptic cleaning and dressing of wounds to prevent contamination thereof • Using wound care aids • Suturing of wounds • Removing clips, sutures, etc • Taking wound swabs • Ensuring the rest and comfort of the wounded area • Assessing the progress of the wound and the early identification of problems.

Key ethical considerations • The promotion of wound healing will shorten a patient’s hospital stay. It is therefore the duty of nurses to facilitate healing and minimise complications. • The final appearance of a healed wound, especially if the area is open to view, is very important. Good healing facilitates the acceptable appearance of the healed wound. • Good healing also promotes the maintenance of function of the wounded area. • Nurses should prevent contractures and deformities from developing during wound healing.

Essential health literacy • The factors that facilitate wound healing should be emphasised – that is, rest and a balanced diet, as well as the importance of keeping the wound clean. It is important to leave the wound and the wound area undisturbed during the healing process. This reduces the risk of contamination and infection of the wound, and promotes healing. • The appropriate first-aid management of various types of wounds and wound care should be taught to the general public.

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Introduction The role of the skin is to protect the underlying tissues and structures. Loss of skin integrity through wounds or skin breakdown of any sort means the loss of this protection. The preservation of skin integrity, the promotion of wound healing and the prevention of skin breakdown are all important aspects of the basic nursing management of patients. Nurses will be encouraged to develop an understanding of the function of the skin, as well as the factors that influence the health of the skin and wound healing. Nurses will be assisted to become proficient in the assessment of the condition of the skin, and the identification and classification of wounds and other common skin lesions. They will also be assisted to become competent in measures that will maintain the condition of the skin, promote the healing of wounds, and prevent skin breakdown. They will thus be in a better position to develop effective care plans for patients suffering from altered skin integrity, including the evaluation of care and the monitoring of patient progress.

The anatomy of the skin The skin or integument and its appendages – that is, the hair, the nails, and sweat, sebaceous and mammary glands – is the largest organ as it covers the entire body. It varies in thickness from 0.5– 4.0 mm. The skin has two main parts: • The epidermis • The dermis. The epidermis is the outer layer of the skin. It consists of stratified squamous epithelial tissue, containing keratinocytes, which contain keratin, melanocytes, a brown pigment that contributes to skin colour, and Langerhans cells, which are macrophages that protect the skin against infection. The dermis is the part of the skin below the epidermis. It consists largely of connective tissue containing collagen and elastic fibres. The other structures in this part of the skin are blood and lymph vessels, sweat glands and ducts, sebaceous glands, hair roots and follicles, arrector pili muscles attached to hair follicles and sensory nerve endings. Subcutaneous tissue or hypodermis is the tissue between the dermis and the underlying muscle. It consists of adipose and areolar connective tissue.

Appendages of the skin • The appendages of the skin are derivatives of the epidermis. These include hair follicles and hair, nails, sweat and sebaceous glands. • Hair is visible all over the body, except on the lips, the nipples, parts of the external genitalia, the palms of the hands and the soles of the feet. Hair grows from hair follicles in the skin. It consists of keratinised cells, and is classified into two main types of hair, namely vellus hair, which is short, fine and non-pigmented; and terminal hair, which is longer, thicker and coarser, as well as being pigmented. Hair consists of a root, a shaft and a follicle. At the base of the follicle is the papilla, a loop of capillaries supplying the hair with nourishment for growth. A hair has three layers of keratinised cells. The medulla is the central core. It is surrounded by the cortex that consists of several layers of flattened cells. The cuticle is the outermost layer. This layer is heavily keratinised, providing the hair with strength. 540

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Dermis

Epidermis

Hair pigment is produced by melanocytes. The more melanin present, the darker the hair colour. Hair growth is influenced by nutrition and hormones (androgens). • Nails are epidermal cells that have been changed to hard plates of keratin. Underneath the nail is the nail bed. Because this area is highly vascularised, it is pink in colour. The skin surrounding the base of the nail is called the cuticle or eponychium. The rest of the tissue surrounding the nail border is called the perionychium. • Sebaceous glands in the skin secrete sebum. Sebum is an oily secretion containing lipids. It softens and lubricates hair and skin. If these glands become blocked by sebum, a whitehead or blackhead pimple results.

Stratum lucidum Stratum spinosum Pilosebaceous follicle with hair Hair root

Subcutaneous tissue

Apocrine sweat gland

Stratum corneum Stratum granulosum Stratum germinativum Papillae Superficial vascular plexus Sebaceous gland Arrector pili muscle Nerve Eccrine sweat gland Capillary loop (papilla) Deep vascular plexus Subcutaneous fat

Figure 25.1  Anatomy of the skin and skin layers Sweat glands are distributed all over the body. There are two types: • The eccrine sweat glands, which produce a watery secretion (sweat) to regulate body temperature • The apocrine glands, which produce an odourless white fluid containing protein, carbohydrate and other substances. These glands are found only in the axillae, nipples, areolae, anogenital area, internal ear and the eyes.

The functions of the skin The intact skin is the body’s first line of defence against infection. • It protects deeper body structures and acts as a barrier against invasion by microorganisms and other harmful agents. The skin’s chemical protection mechanisms include secretions that lower the skin pH and retard the growth of bacteria; sebum 541

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•

•

•

•

• •

excreted by the sebaceous glands kills bacteria. Melanin produced by the cells of the skin shields the skin from the sun by preventing ultraviolet skin damage. Langerhans cells are part of the structure of the skin. These cells are macrophages – specialised cells of the immune system that destroy micro-organisms that have managed to penetrate the epidermis. The skin contributes to maintaining the body’s temperature within homeostatic limits (36– 37.0°C). When the body temperature increases above normal, vasodilatation of dermal blood vessels results, with increased sweating. Evaporation of sweat from the skin surface increases heat loss and cools the body. When the body temperature is below normal or the external environment is cold, the opposite occurs. Dermal blood vessels constrict and less blood flows to the skin. Heat loss through the skin is slowed, thus conserving body heat. The skin has an excretory function. It excretes sweat, which contains water, salt (sodium chloride) and limited amounts of nitrogen waste products (ammonia, urea and uric acid). Sensory nerve endings are present in the skin, sensing temperature, pain and pressure (slight touch to deep pressure). The purpose of this is to protect the body from harm by giving warning of damage. The skin also carries out important metabolic functions. When the skin is exposed to sunlight, the skin synthesises vitamin D from modified cholesterol molecules. Vitamin D is necessary for calcium absorption from the digestive tract and calcium metabolism. Calcium is an electrolyte necessary for healthy, strong bone formation. The skin cells produce several important proteins as well as the enzyme collagenase, which is needed for the health of the skin. Enzymes in the skin can convert cancer-causing chemicals to harmless chemicals. The skin can also do the opposite – that is, change harmless chemicals to cancercausing ones.

Effects of loss of skin integrity • Any break in the skin (from the smallest cut to major skin loss due to injury such as in burns) allows micro-organisms to enter the body, causing inflammation and sepsis. • Hypothermia results when major skin damage is present as in major burns. • Excessive fluid loss with dehydration and hypovolaemic shock results when major skin damage is present (as in major burns). • Increased salt loss with hyponatraemia and hypochloraemia results when major skin loss is present. • Slight to severe pain is present when skin is damaged.

Nursing assessment of the skin and skin integrity To be able to plan and implement the appropriate nursing care for a patient with a health problem of the skin, hair and nails, nurses must carry out a thorough assessment, as described below.

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History taking related to the skin and skin integrity To be able to make a correct nursing diagnosis and plan appropriate nursing care, adequate information must be obtained during history taking. The following are examples of questions to ask: • Have any skin changes occurred recently? What type of change has occurred? –– A colour change? –– A change in the texture of the skin? –– A change in the temperature of the skin? Are there areas of skin that feel warm or cold? –– Has the skin become excessively dry? –– Has a rash developed? –– Have any lumps developed? –– Is there a wound or lesion that does not heal? –– Have there been any changes in a wart or mole? What are the changes, for example enlargement, colour change, change in appearance, bleeding? • Are there other signs and symptoms, such as: –– an itching or burning sensation –– pain –– exudate (colour, amount, odour, consistency) –– bleeding –– thinning of the skin –– fever –– excessive/increased sweating? • Where on the skin is the problem? Which part of the body is affected? (This could be skin covering the hand, leg or face.) • When did the problem first start? • Has the skin been recently exposed to drugs; chemicals, including soaps, oils and lotions; persons with the same skin problem? • Find out if the patient has been travelling recently, and if so, where to and for how long. Was the patient exposed to any illnesses while away? • What is the patient’s explanation or perception of the cause of the skin problem? • What treatment has the patient implemented for the problem? What was the response to the treatment? • What factors improve or worsen the problem? • Are there any hair problems, for example: –– abnormal hair loss or growth –– changes in hair texture –– split ends? • Are there any other signs and symptoms related to the hair, for example itching, dandruff, sores, pain? • Has there been any recent exposure to hair treatments, such as colouring or a perm? • Are there any changes in the nails, such as splitting, breaking, discoloration, thickening?

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• Are there any other health problems that could impact on the health of the skin, such as: –– cancer, cancer treatment with chemo- or radiotherapy –– diabetes mellitus –– cardiovascular disease: arterial insufficiency of the lower limbs, varicose veins, deep-vein thrombosis, previous varicose ulcers, and cardiac failure –– liver disease –– endocrine disease, for example thyroid dysfunction –– previous history of skin cancer, nail or hair problems, other skin problems? • Is there any history of skin allergies, such as dermatitis, atopic dermatitis? • What is the patient’s current medication? –– Antibiotics can be the cause of an allergic reaction. –– Is there long-term use of steroids (cortisone, medrol, prednisone)? –– Anti-inflammatory drugs (Brufen, Voltaren, etc) may mask symptoms of an infection. • If skin cancer is the probable cause for the patient’s current skin health problem, find out about any skin cancer risk factors: –– Family history of skin cancer/cancer –– Age of patient –– Skin complexion: fair, freckled, ruddy, dark –– Hair and eye colour: risk is high in people with a light colour –– Tendency to sunburn easily –– Overexposure to the sun (recreational or occupational) –– Overexposure to X-rays –– Repeated trauma or irritation to the skin. • Determine the presence of psychological problems if found to be present. • Determine whether a balanced diet is followed. If allergy is suspected, determine what the patient ate before the rash or other symptoms appeared. • Determine the patient’s occupation, as this may indicate exposure to environmental or occupational hazards, such as contact with chemicals or toxic substances. • Determine the patient’s alcohol use. Is it such that skin changes may have taken place due to liver disease? In the case of infants or very young children, determine the following: • Feeding history: breast or bottle-fed, type of formula, foods recently introduced • Diapers: disposable or non-disposable type used; washing practice of nondisposable nappies; the type of detergent used to wash nappies and whether these are thoroughly rinsed after washing and sterilising • Frequency of nappy change • Washing practices of clothes and bedding: again taking into consideration the type of detergent used to determine if this can be the cause of skin irritation or allergy • Skin and hair cleaning practices: regularity and method of cleaning the nappy area, baby bathing, and types of product used • Oils and other moisturising lotions • Immunisation schedule: whether the child has recently been immunised 544

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• Childcare: is the infant or child in the care of a crèche or nursery school where there may be exposure to communicable diseases?

Physical assessment of the skin and skin integrity Physical assessment of the skin, hair and nails involves inspection and palpation. Skin inspection

Observe the general physical and psychological condition of the patient. Note whether the patient appears ill or whether other health problems not mentioned by the patient are present. Inspect the skin of the entire body. Colour of the skin. Note any abnormalities, such as the following: • Blue appearance of the skin. This condition is called cyanosis, and is due to inadequate oxygenation of haemoglobin. In dark-skinned individuals, the skin does not appear cyanotic because of the dark colour, which is due to the amount of melanin in the skin. Cyanosis can be observed in the mucous membranes and nail beds of dark-skinned individuals. • Redness of the skin may be due to blushing, fever, allergy or inflammation. • Pallor may signify anaemia. • An abnormal yellow skin colour due to yellow bile pigments accumulating in body tissues is known as jaundice and is due to liver disease. Jaundice in dark-skinned individuals is best seen in the sclera of the eyes. • White skin patches on the skin are known as vitiligo. Vitiligo is most noticeable in dark-skinned individuals, and may be due to hyperthyroidism, pernicious anaemia or adrenocortical insufficiency. • A port-wine stain is the most noticeable of birthmarks. The stain manifests as pink to deep-red blotches on the face, a limb or trunk of the individual. • Bronzing of the skin of fair individuals may be due to Addison’s disease, chronic kidney failure or chronic liver failure. Skin thickness. Note any abnormalities, for example thin, shiny, easily breakable skin: • Hair growth on the skin. Note the presence and condition of hair on the skin. For example, there may be abnormally increased facial hair growth in females, sparse or no hair growth on the lower limbs due to arterial insufficiency. • Observe the amount of sweating. Normal sweating is not visible. If increased sweating is observed, the possible causes are: –– high environmental temperature –– fever –– hormonal imbalance (menopause). • Observe for skin oiliness particularly if the patient is complaining of facial lesions. • Observe for signs of skin dryness – dry skin will appear flaky. • Observe for striae and birthmarks. Striae are stretch marks on the skin of the patient, and may be caused by weight changes and pregnancy. If applicable, ask whether the patient has lost or gained a lot of weight recently. • Observe the patient’s hygiene. If the patient’s hygiene is poor, this may be the cause of the skin problem. 545

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Palpation of the skin

The skin is palpated, or felt, to elicit the information described below: • Temperature. To assess the skin temperature, the back of the hand is placed lightly on the skin surface to ‘feel the temperature’. Should the patient complain about a specific skin area, or a lesion is observed, the temperature of the affected area is assessed and compared with the temperature of the rest of the skin. Possible causes for a localised skin temperature change include the following: –– Inflammation or infection if the skin is warmer –– Arterial insufficiency due to vasoconstriction of arteriosclerosis if the affected area is colder than the rest of the skin. • Texture. This involves assessing the smoothness or otherwise of the skin. The nurse should feel whether the surface of the skin or lesion is smooth or rough, soft or leathery. Well-cared-for skin should be smooth and soft. Rough, leathery skin may be due to decreased skin hydration and long-term overexposure to the sun. However, many skin diseases including hypothyroidism may cause a rough skin surface. • Elasticity, mobility and turgor. Normal skin is highly elastic and mobile. Skin turgor refers to tissue tension and it is measured by the ability of the skin to return to normal after being stretched. To assess skin elasticity and turgor, the skin is pinched between two fingers, lifted and released. The skin turgor is normal when the stretched and lifted skin returns to normal position immediately. Turgor is decreased when it takes longer for the skin to return to normal position. Decreased turgor may indicate dehydration. The skin of an elderly patient will demonstrate decreased elasticity, loose folds and wrinkles, and decreased turgor because of collagen and elastic fibre loss, which are part of the normal process of ageing. Oedema and skin diseases may decrease skin mobility. Inspection and palpation of all skin lesions and moles

Skin lesions and moles must be inspected and palpated for the following: • Size • Shape • Colour • Location • Pattern of distribution • Texture • Effect on skin mobility.

Assessment of the hair and nails • Hair. Hair growth, distribution and condition can be a good indicator of the person’s general health. Colour, distribution and quality of the hair determine the texture. Excessive hair growth in a female should be noted and may be due to hormonal changes, for example menopause. Abnormal hair loss causing areas of baldness should be noted. Causes of this could be general ill health, hormonal imbalance, infection of the scalp or chronic liver disease. Any lice or nits in the hair should be noted. • Nails. Inspect the colour, length, configuration, symmetry, adherence to the nail bed and cleanliness, and also note any ridging or clubbing. The nails should be palpated 546

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for texture, firmness, contour uniformity and thickness. The skin area surrounding the nail should be palpated for injury, redness, swelling, pain and exudate.

Assessment of pressure areas Assessment of the pressure areas of the patient involves obtaining a history as well as inspection of pressure areas. History taking involves determining the risk factors for the development of pressure sores (decubitus ulcers). These risk factors include immobility, incontinence, sweating, malnutrition, poor blood circulation to the tissues, and the use of steroids and anti-inflammatory drugs. The aged are at a higher risk for pressure ulcers because of loss of subcutaneous fat and decreased skin elasticity, combined with generalised atrophy of the skin due to ageing. The thin, underweight patient and the obese patient are also at high risk for developing pressure ulcers (see Chapter 22 ‘Mobility and exercise need’). Inspection of pressure areas

The following should be noted: • Skin colour – observe for red mottled skin that does not return to normal colour when pressure is relieved. • Note blistered or broken skin. • Note any exudate in areas where the skin is broken. • Note any actual pressure ulcers. If a pressure ulcer is present, observe the size and depth. Observe the appearance of the tissue: whether this is healthy, inflamed, swollen, infected or necrotic.

Stages of a pressure sore Stage 1: Pressure area is red. This remains present after pressure is removed. Skin is intact. Stage 2: Skin is broken. Lesion is superficial. Stage 3: Full-thickness skin loss – subcutaneous tissue may be included. Stage 4: Full-thickness skin loss through muscle, tendon and down to bone level. Various sinuses present.

Clinical alert! Pressure areas should be assessed on admission of a patient to a healthcare institution, or at the first visit if the patient is being cared for at home. Thereafter, assessment should be done every time back and pressure care are done.

Management of common clinical skin problems Principles of skin care To maintain skin health and prevent skin health problems, the following factors are essential: • Adequate hygiene of the skin 547

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• Balanced nutrition • Avoidance of skin-damaging agents • Early detection and managing of skin and mole abnormalities. Hygiene

It is the responsibility of nurses to assess the hygiene needs of their patients and to implement the necessary nursing procedures, such as bed-bathing, baby bathing or assisting the patient to bath. Regular bathing is essential for the maintenance of a healthy skin. Normal skin should be washed regularly to remove excess oils and sweat, and also to prevent odour. Care must be taken to prevent dryness and irritation of the skin that leads to itching, followed by scratching and injury of the skin. Strong alkaline soaps should be avoided because these may neutralise the protective acid balance of the skin, which inhibits the growth of harmful bacteria. Strong soap also removes the lubricating oily secretion of the sebaceous glands, causing skin dryness. A lubricating lotion or cream may be applied to the skin after bathing to prevent or treat dryness. Balanced nutrition and skin health

All the elements of a balanced diet, in sufficient amounts, are needed for skin health: • Protein • Carbohydrate • Fat • Vitamins A, B-complex, C, K • Electrolytes and trace elements, including iron, zinc and copper. Table 25.1  Nutrition and skin health Nutrient

Function

Result of deficiency

Protein

Needed for formation of new skin cells. In the woundhealing process it aids in neo-vascularisation, fibroblast proliferation, collagen synthesis, lymph formation and wound healing

Decreased resistance to infection Dermatological health problems, for example: • skin infections • retarded wound healing • thin, easy breakable skin

Albumin

Ensures osmotic homeostasis

Hypo-albuminaemia leading to generalised oedema. Oedema slows oxygen diffusion and transport of nutrients to skin cells

Carbohydrate

Needed for production of energy for cells, including collagen and proteoglycan synthesis

Decreased energy production leading to decreased function of skin cells. Impaired collagen synthesis decreases resistance to ➙ infection

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Nutrient

Function

Result of deficiency

Fat

Needed for production of energy for cells and the formation of new cell membranes

Inhibited skin repair

Vitamin A

Co-factor for collagen synthesis and cross-linkage of the fibres in the skin. Stimulation of fibroplasia and epithelialisation

Altered collagen synthesis and crosslinking of fibres resulting in: • Decreased skin strength and stretch-recoil ability of skin • Decreased epithelialisation in wound repair

Vitamin B-complex

Contributes to formation of antibodies and white blood cells

Decreased resistance to infection

Vitamin C

Co-factor in lysine and proline hydroxylation process. Needed for collagen secretion and cross-linking of fibres in the skin. Essential for resistance against infection. Improves capillary formation

Decreased resistance to infection Decreased skin strength Increased capillary fragility

Vitamin K

Needed for blood coagulation

Increased risk of haemorrhage and haematoma formation

Iron

Needed for hydroxylation of lysine and proline in collagen synthesis. Causes anaemia, leading to skin tissue hypoxia

Impaired collagen cross-linkage and decreased skin strength

Zinc

Co-factor needed in numerous enzyme systems involved in cellular proliferation. Cell membrane stabilisation

Reduced epithelialisation rate Decreased collagen synthesis, leading to decreased skin strength

Copper

Essential for collagen synthesis and cross-linking of collagen fibres. Decreased collagen synthesis

Decreased collagen synthesis

Avoidance of skin-damaging agents

Hygiene and balanced nutrition alone will not assure skin health. Skin-damaging agents must also be avoided. These include the following: • Overexposure to the ultraviolet rays of the sun, which cause skin damage. Ultraviolet rays (UV) consist of UV-A and UV-B waves. UV-A waves contribute to skin ageing and the development of skin cancer. UV-B waves cause sunburn and tanning. • Trauma by scratching, burning, cutting, tearing, abrasion, pressure, friction, corrosive chemicals, biting (by humans, animals and insects).

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Exposure to allergens, micro-organisms and parasites

• Exposure to allergens causes allergic disorders of the skin, such as allergic and atopic dermatitis, urticaria and pruritis. • Exposure to micro-organisms and parasites may cause skin infections. Exposure of skin to continuous pressure and friction

• When the pressure areas of a bedridden patient or person in a wheelchair are exposed to continuous pressure and friction, pressure ulcers result. • Pressure areas or pressure points on the skin are body areas where pressure results when a person sits or lies down, because of bony prominences lying close to the skin. • Friction develops when two surfaces are dragged across each other in opposite directions. Initially, resistance occurs between the two, and force must be generated to overcome it before the two surfaces will move across each other. When a patient is dragged in bed by nursing staff or home helpers, friction results, which is increased if the patient’s bedding is wet, the patient is heavy or the bony prominences are pressing against the mattress. Early detection and managing of skin and mole abnormalities

To detect skin disease early and limit skin damage, the nurse should advise individuals to inspect their skin after bathing for abnormalities. Moles must be inspected for changes in colour, size and shape, and for bleeding. Abnormalities must be reported to a doctor or nurse to ensure that problems are managed in good time.

Common skin problems Common skin problems and their management are described below. Corns

• The patient should wear shoes that fit properly. • Felt corn protectors can be applied to protect small corns. • As a last resort, corns can be removed surgically. Calluses

• The patient should wear shoes that fit properly. • Skin lotion or cream can be applied to keep the skin soft. Acne vulgaris

• It is important to ensure that everything possible is done to optimise skin health: good hygiene, balanced nutrition, stress reduction and treatment of skin infections. • Topical treatment includes creams (antibiotics, anti-fungal, steroids and vitamin enriched) and lotions as prescribed. • Systemic medication includes antibiotics and isoretinoic acid (Roaccutane). • Surgical removal of unsightly scars can be undertaken.

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Psoriasis

• Topical preparations are applied to soften the skin and reduce irritation: bland emollients, coal tar preparations and cortico-steroids. • Oral cortico-steroids can be given for their anti-inflammatory effect. • Ultraviolet light therapy is used to reduce irritation. • Anthralin products such as Anthranol, which are antimitotic, are used to reduce overproduction of epithelial cells. Methrotrexate, also an anti-mitotic agent, is also used in psoriasis. Tumours of the skin

• It is important to prevent overexposure to the sun and sunburn. • Skin tumours can be removed surgically. Skin grafting may be needed after removal. • Many skin cancers respond to radiotherapy or chemotherapy. Dermatitis

• Dermatitis includes contact dermatitis, allergic dermatitis and dermatitis medicamentosa. • Prevent contact with the causes: allergens, chemical irritants, mechanical irritants, medication. • Use topical medication – apply cortico-steroid and antihistamine creams and lotions as prescribed. • Use calamine lotion for pruritis. Infestations (head and body lice)

• Wash hair with pediculicide shampoo. Allow the product to remain on the hair for the prescribed period. Use fine-toothed comb to remove dead lice and nits. Repeat treatment in 8–10 days. • Apply pediculicide lotion or cream to affected areas in the case of body lice. The patient should take a bath after 12 hours. Scabies

• Eliminate the female itch mite with topical treatment: shampoo, lotion and cream containing benzyl-benzoate, crotamiton (Gambex, Ascabiol). • Repeat the treatment after 24 hours. Fungal infections (candidiasis)

There are many preparations used. These can be systemic or locally acting. • Exclude predisposing factors: poor nutrition, broad-spectrum antibiotics. • Use nystatin (Mycostatin) topical medication for oral treatment. • Use ketoconazole (vaginal candidiasis) vaginal cream and pessaries. Also, keep the genital area clean and dry, and loose, absorbent underclothing should be worn. Tinea pedis (athlete’s foot)

• Prevent sharing of baths, showers, towels, etc, with infected persons. • Use Mycota foot powder (zinc undecenoate and undecenoic acid). 551

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Tinea capitis (ringworm)

Use ketoconazole shampoo (Niz). Warts

Most will disappear in time without treatment. • Cryosurgery – the lesion is frozen with liquid nitrogen. • Electrodesiccation – the top of the wart is sealed and then the wart is curetted off. Herpes simplex (Type I)/fever blister

Apply topical antiviral cream: acyclovir (Zovirax). Herpes zoster (shingles)

Most patients need no treatment. • Use acyclovir (Zovirax) cream. • Use analgesics (aspirin and codeine) for treatment of pain. • Use systemic steroids (Prednisone).

Essential health promotion and health education It is the nurses’ responsibility to inform the community on what to do to ensure a healthy skin.

Commonly used skin care products • Soap is used for cleaning the skin, nails and hair. The best choice is a mild soap with a pH as close as possible to skin pH. • Cosmetic skin products are used for cleaning and softening the skin. • Deodorant is used to diminish body odour. • Antiperspirant is used to reduce the amount of sweating. • Bath oil is used in bath water to soften the skin. • Skin lotion is used to soften dry skin. • Sunscreen lotion is used to protect the skin against sun damage. It is rated by the percentage sun protection factor (SPF) present in the lotion. • Powder is used in certain areas prone to friction, for example under the breasts of women. It also lends a pleasant smell to skin. General health education General health education for the care of the skin and the prevention of health problems is an important aspect in the maintenance of a healthy skin. • Hygiene is important in maintaining the health of the skin and avoiding the growth of potentially harmful bacteria. Daily bathing or washing with a mild soap is recommended. • A healthy balanced diet is essential for the health of the skin. The person’s diet must be assessed, and advice must be given to assure this is achieved within cultural parameters and financial constraints. In this respect, each patient is an individual and must be treated individually.

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• Every family must know the importance of preventing injury and burns to keep the skin intact. Abrasive substances such as rough materials for washing and strong chemicals in the form of detergents, creams, ointments and lotions that can cause the skin to break must be avoided. • Contact with persons who have an infestation should be avoided. If an infestation does occur, it should be treated promptly, as irritation and itching may lead to skin breakdown and possible infection. The local clinic and the casualty department, as well as most pharmacies, offer advice and assistance in getting rid of parasites. • Sun exposure is implicated in premature skin ageing and also in the development of skin cancer. Although darker-skinned people have more natural sun protection than fair-skinned ones, excessive sun exposure will ultimately cause damage in all individuals. People should be educated regarding staying out of the sun wherever possible, avoiding sunburn, wearing suitable clothing to protect themselves from the sun and using sun-blocking agents on areas that are exposed to the sun. • Skin problems should be treated at an early stage rather than later. People should visit their medical practitioner or their local clinic as soon as a skin problem that is not amenable to simple remedies is detected.

Health education for specific skin problems This is an important aspect of empowering the community for the maintenance of optimum health and for effective self-care. Acne vulgaris

Patients should be advised regarding the prescribed medication. This includes the indications; the reason why the medication is prescribed, and the importance of taking it as prescribed; the dosage and times the medication must be taken; whether medication should be taken with or after meals; and side effects and what to do about them.

Clinical alert! If tetracycline is prescribed, the following specific advice should be given: • The medication should not be taken with milk. Milk or antacids should not be ingested for approximately one hour before or after taking the medication. Milk binds with tetracycline and decreases absorption of the medication. If a topical preparation is prescribed, patients should be advised as follows: • The medication should be applied as prescribed, not more frequently or less frequently; hands should be thoroughly washed before applying the topical medication. A thin layer should be applied unless otherwise prescribed. If clean unused disposable gloves are available, they can be put on before applying medication to the skin.

Good hygiene is important in acne vulgaris: • The face and other affected areas should be washed twice a day with water and a mild soap. • Towels and pillowcases should be changed daily. Used towels and pillows should be washed with warm water and dried in the sun. 553

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• The hair should be washed at least every second to third day. • Hands must be kept away from the face – touching affected areas with unwashed hands, and especially squeezing lesions on the face, must be avoided. • If possible, the patient should not use make-up, as this tends to clog the pores. A healthy lifestyle is important: • A balanced diet should be taken. The nurse must assess the patient’s eating habits and give advice to ensure a healthy diet. The eating of chocolate and fatty foods should be avoided. This is not the cause of acne, but eating such foods decreases the eating of healthier foods like fruit and vegetables. • Smoking cigarettes should be avoided. • Stress should be reduced and physical activity increased. Dermatitis in the nappy area (nappy rash)

All mothers should receive health education on how to prevent and treat dermatitis in the nappy area. A baby’s nappy should be changed as often as possible: • Check if the baby is wet every 30 minutes or so. • The nappy area should be wiped with a clean, wet cloth. • Avoid using soap to wash the baby’s nappy area. If the mother wants to use something, a water-based cream is better. Large containers are available at chemists at a minimal price. • Dry the baby well. • Put on a clean and dry nappy. Avoid dressing a baby with waterproof pants over the nappy. These encourage lessfrequent nappy changes and closer contact between wet nappy and the baby’s skin. If the baby is prone to nappy rash, products are available from shops or the chemist to form a protective layer over the bottom. Several baby rash ointments which soothe and protect a baby’s nappy area are available. In addition to the above advice, should a nappy rash be present, the mother can be advised as follows: • The baby’s nappy should be changed more frequently. • Leave the baby without a nappy as often as possible to allow fresh air to circulate around the nappy area. • Do not use disposable nappies. Change to the towelling type. • The nappy should not be applied too tightly. • Nappies should be sterilised. The instructions accompanying the chosen sterilisation product should be followed carefully. • If it is not possible for the mother to change to towelling nappies, she can be advised to change to another make of disposable nappy. • The mother must be advised to take the baby to a doctor if the condition remains unchanged for five to seven days. Topical medication may then be prescribed. Psoriasis

Specific health education should be given to a patient with psoriasis to ensure that the skin remains in optimum condition and lesions are kept to a minimum: • Explain the cause of the disease. 554

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• Explain that it is a chronic disease. At times it will improve and at other times worsen. • Advise that the disease is not communicable, but it is very sensitive to stress, which causes the size and severity of lesions to increase. • Advise that, psychologically, a positive outlook will reduce stress and contribute to improving the patient’s skin condition. • Recommend the wearing of clothes that cover the lesions. • Recommend medication: explain the reason and importance of prescribed medication, the dosage and times, and application method, as well as the side effects. • Advise the patient to follow a healthy lifestyle, including a healthy balanced diet and adequate fluid intake, to reduce stress, to avoid smoking, to prevent overexposure to the sun and sunburn, and to follow an active lifestyle. • Recommend that the patient consult his or her medical practitioner before using any unprescribed medication, because this may worsen the skin condition. • Advise that, if there are lesions on the scalp, a short hairstyle should preferably be worn. Pediculosis (head lice)

Head lice are easily spread in institutions such as schools and hostels where ablution facilities are shared. However, a few simple measures can help to prevent the spread of head lice: • Combs and hairbrushes should never be shared. • Towels should also not be shared, especially if a person has head lice. • It is prudent for mothers to inspect their children’s hair on a weekly basis to see if a stray louse is present, because it is much easier to treat the infestation if it is picked up early before the parasites have multiplied to great numbers on the head. • If a child has head lice, he or she should be kept at home for a day, and treatment for head lice should be implemented. • Everyone who has had close contact with the affected person should be assessed and treated. • Wash the affected person’s hair with special shampoo for head lice, for example Ascabiol, Quellada, Lyclear or Gambex. A pharmacist will be able to advise on what is current and available. Follow the instructions on the product. • Brush the person’s hair with a fine comb until no nits or eggs are present. • Repeat washing of hair as per instructions on the product to ensure the removal of any nits that have hatched since the first application of the product. • Wash the affected person’s towels, bedding and clothing in hot water. Dry them in the sun. Clothes should be ironed with a hot iron, giving special attention to seams where nits and lice may take refuge before migrating to the head. • Wash combs and brushes thoroughly in hot water. • Assess the person’s hair weekly for lice and nits until satisfied that the problem is solved.

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Wounds and wound healing A wound is a break in the continuity of the skin.

Classification of wounds Wounds are classified according to the cause, duration and condition of the wound: • Wounds may be acute or chronic. Acute wounds are wounds that occur suddenly. Most heal fast by primary intention, for example surgical or clean traumatic wounds. Acute wounds may become chronic when healing is delayed because of infection, decreased perfusion, venous stasis and severe malnutrition. These wounds can take up to three months and longer to heal. Examples of chronic wounds include the following: –– Pressure ulcers (decubitus ulcers) –– Venous ulcers, which are ulcers on the lower part of the legs due to venous stasis –– Wounds on the lower part of the legs due to severe arterial insufficiency. • Wounds may be described as closed or open. Closed wounds can be surgical or traumatic wounds, which have been closed by stitching, clips or wound tape. Open wounds are surgical or traumatic wounds that have been left open when the edges of the wound cannot be approximated because of contamination, infection or extensive tissue loss. • Wounds may also be classified as clean or dirty, depending on the degree of contamination of the wound. Clean wounds are uninfected. Clean wounds are normally closed wounds, and the alimentary, genital and urinary systems are not involved. Clean-contaminated wounds are surgical wounds in which uninfected alimentary, genital or urinary systems have been operated upon. Contaminated wounds include surgical and traumatic wounds and open wounds. Contaminated traumatic wounds have been contaminated during injury, for example by sand. Surgical wounds can be contaminated due to a major break in sterile technique or spillage of gastrointestinal contents into the wound during surgery. • Infected wounds are wounds with evidence of infection. In this instance, laboratory tests would reveal the presence of micro-organisms in the wound. The wound is red and swollen, and a purulent drainage may be present. Types of wound There are various types of wound, for example surgical wounds that have been caused by a surgical incision, and traumatic wounds that have been caused by trauma. Various types of injury can be identified in the category of traumatic wounds: • An abrasion is a superficial open wound caused by friction, for example falling and scraping the knee. • A laceration is a deeper wound where the tissues are torn, resulting in irregular wound edges. • A puncture wound is an open wound made by a sharp instrument, for example a stab with a knife or from stepping on a nail. • A penetrating wound is a wound that extends deeply into tissues (eg a gunshot wound) or a stab wound that penetrates deeply into the tissues, possibly damaging internal organs.

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• An incision is a cut in the skin and underlying tissues made by a sharp instrument (eg a knife). The edges are usually smooth. • A contusion is a closed wound caused by a blunt instrument. The skin is bruised. • Burn wounds are due to thermal, chemical, electrical and radiation damage. The depth varies from superficial (first degree) to deep (third and fourth degree), depending on the extent of the damage to the epidermis and the dermis.

Wound healing The wound healing process is the body’s normal response when a wound occurs. The process consists of three phases: 1. Inflammation 2. Fibroblastic proliferation and angiogenesis 3. Wound remodelling and maturation. Wound occurs Wound remodelling and maturation

Inflammation Proliferation and angiogenesis

Figure 25.2  The wound healing process Successful wound healing depends on adequate nutritional stores and hormones produced by the body. These hormones include the following: • Growth hormone from the pituitary gland. Growth hormone increases cell permeability for protein. The increased protein in cells of the wound area is used for wound repair. • Cortisol from the adrenal cortex • Thyroxine originating from the thyroid • Glycogen originating from the pancreas. Cortisol, thyroxine and glycogen mobilise nutritional substances from nutritional stores, needed for wound repair, and increase in the body’s metabolic rate. Factors affecting wound healing

Internal factors. These are factors within the patient’s own body that may accelerate or retard the healing of wounds. • Blood supply to the area is important. An adequate blood supply facilitates healing, while a poor blood supply retards healing. • Immunological factors influence healing. Immune deficiency will reduce the formation of antibodies and lymphocytes that are necessary to prevent wound infection. • Wound healing is delayed in malnourished patients. • In patients with diabetes mellitus, other chronic illness, infection and those on cancer therapy, wound healing is delayed. 557

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• Wound healing in the elderly may be delayed because of many causes: atrophy of capillaries in the skin, decreased growth factors, nutrition deficiencies, etc. • Adipose tissue has limited blood supply, decreasing nutritional supply for wound healing, which tends to retard wound healing in obese individuals. In obese patients, the stress on sutured wounds is increased, and dehiscence is a distinct possibility. • Smoking decreases the oxygen supply to the wound and contributes to hypercoagulation. External factors. These are factors in the environment that will impact on wound healing. • The longer the patient’s stay in hospital, the greater is the risk for infection. • Pre-operative preparation of the operative area is important. Patients must bathe before surgery to ensure hygiene. An antiseptic soap may be used to decrease the number of micro-organisms on the skin. • Maintaining the highest level of aseptic technique intra-operatively and during wound care decreases the risk of infection. • The wound care method must ensure protection of the wound from contamination and pressure, and encourage healing. • Unnecessary opening and cleaning of wounds increases the risk of infection and delays healing.

The wound healing process Inflammation

The first phase. The inflammation phase commences immediately after injury and lasts for four to six days. During this phase, the following activities occur in the wound: • Haemostasis – blood, serum proteins and clotting factors move into the wound. Fibrin enhances clot formation to seal off bleeding points. • Small blood vessels dilate, and capillary permeability increases. This results in the leakage of fluid and other molecules into the interstitium. • Neutrophils move into the wound to assist in preventing infection by phagocytosis. • Monocytes enter the wound and differentiate into macrophages. Their function is to digest necrotic tissue and remove debris in the wound. Other functions of the macrophages include inhibiting bacterial growth and releasing of growth factors that stimulate wound healing. Macrophages also play a role in the induction of collagen synthesis. • Platelets, activated by thrombin, release growth factors that stimulate healing. During the inflammatory phase, the wound shows signs of redness (erythema), swelling and tenderness, and a non-purulent exudate is present. It is of crucial importance to realise that these are signs of the first phase of wound healing and not of infection. Fibroblastic proliferation and angiogenesis

The second phase. Fibroblastic proliferation and angiogenesis constitute the second phase of wound healing. The stage begins on day 1 to day 4, and ends on days 14–21 after the injury. During this phase the following activities occur in the wound: • Rapid growth of epithelial cells, producing a protective covering for the wound 558

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• Formation of new capillaries, followed by the formation of granulation tissue and collagen synthesis • Cross-linking and overlapping of the collagen fibres to increase the tensile strength of the wound and provide wound integrity • Filling in of the gaps in the wound by collagen fibres, and the formation of a scar. Wound remodelling and maturation

The third phase. This is the last phase of wound healing. It begins on day 14–21 and ends between six months to two years after the injury. During this phase the following activities occur in the wound: • Specialised fibroblasts, the myofibroblasts, cause contraction that assists in moving the wound edges to the centre of the wound. • The wound scar softens and flattens. • Tensile strength increases, but full tissue strength may in some instances never be regained. Healing by primary intention

The healing of a wound by primary intention occurs when the tissue surfaces have been approximated or brought together (with sutures, clips or wound-closing strips) where there is minimal or no tissue loss. Healing by secondary intention

Extensive wounds, characterised by considerable tissue loss, heal by secondary intention. In secondary intention healing, wound repair time is longer, the scarring is greater and there is a greater risk of infection. Because it is not possible to close the wound with clips or sutures due to the extensiveness of the injured area, the wound is left open and heals by granulation. Healing by tertiary intention

Contaminated traumatic wounds and infected wounds heal by tertiary intention. Initially such wounds are left open until infection has cleared, then the wound edges are approximated and sutured or a graft is applied.

Wound assessment Accurate wound assessment is an essential skill for the nurse so that appropriate treatment decisions can be made. Wounds are assessed by obtaining a history from the patient, followed by inspection of the wound and use of the sense of smell to identify any offensive exudate. History and general patient information

The following needs to be noted: • The patient’s medical diagnosis • The patient’s age • The weight of the patient: whether the patient is underweight or obese • The patient’s nutritional status • Medication in use: antibiotics, anti-inflammatory drugs, steroids, anti-coagulants 559

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• Other health problems present: diabetes mellitus, cardiovascular disease, etc • Whether the patient is on radiotherapy or chemotherapy • Social history of patient: alcohol consumption, smoking habits (How many cigarettes a day? Is chronic obstructive airway disease present?). Wound history

The following should be noted: • Location of the wound • Type of wound: acute or chronic, surgical or traumatic, open or closed • Duration: date wound was acquired • Current wound treatment: cleaning solution, topical medication used, type of wound • Dressing and frequency of wound care. Inspection of the wound and surrounding skin

Inspection should include the following: • The size: the length, width and depth in cm. Calculate the wound surface in cm with the formula: width × length (if applicable). • The colour of the wound: is it black (necrotic tissue present), yellow (slough present), red (granulation tissue present), pink (healthy epithelialisation or infected) or a combination of colours? • The wound edges: observe the appearance – whether healthy, approximated, indented or macerated. • Observe the wound for exudate. Note the amount of exudate: normal or increased? • The colour of the exudate should also be noted, whether clear, serous, bloody, blood stained or purulent. • Observe the condition of the surrounding skin. Note whether the skin appears healthy and intact, or the opposite. Observe for redness, swelling and erosion. If the skin is healthy and intact, plaster can be used to secure the wound dressing. Other methods must be used if the skin appears unhealthy. If the surrounding skin is unhealthy and broken, the risk of delayed healing and wound infection is increased. Palpation of the wound and surrounding area

The wound area should be palpated to determine whether an increase in temperature is present, or whether the wound area is tender or painful to the touch. Identification of odours emanating from the wound

Using the sense of smell, determine whether an odour characteristic of an infected wound is present. Note: If a wound is large and open or chronic, measuring the size and taking a photograph every 10–14 days can give concrete information: • to motivate the patient because change can be seen • to assess the success, or otherwise, of treatment implemented.

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Assessment findings in wound infection History • There is a history of wound contamination. • The patient complains of feeling ill, and the signs and symptoms of infection are present – that is, malaise, loss of appetite, fever, increased wound pain. Inspection findings • The wound is red and swollen. Cellulitis is present. • Fragile granulation tissue is present. Slough and necrotic tissue may also be present. Increased exudate production is noted, which may be purulent. • Deterioration of the wound can be seen, and the wound fails to heal. Diagnostic findings • Wound swab culture report from laboratory will show the presence of bacteria and its sensitivity.

Nursing implications • Ineffective treatment, based on inadequate assessment, may lead to complications. • Inadequate cleaning/debridement may predispose to wound infection. Always clean a wound thoroughly and remove all visible debris and dead tissue. • The correct selection and appropriate use of wound dressings and lotions are important. The inappropriate selection and use of such aids may actually retard healing. • All wound treatment should be scientifically based. Weird and wonderful remedies and treatments are not recommended, and could even be considered unethical and unprofessional.

Principles of wound care and promotion of wound healing Appropriate treatment will depend on the cause and type of wound, and may include the following: • Cleaning • Debridement • Wound closure with sutures, clips or skin closure strips • Wound dressings • Skin grafting • Medication: antibiotics and anti-inflammatory medication. Wound cleaning

Following injury, all wounds must be thoroughly cleaned with plain water, sterile water or sterile sodium chloride 0.9% to wash away any dirt introduced at the time of injury. Antiseptics containing iodine, hydrogen peroxide, alcohol, hypochlorite, acetic acid and chlorhexidine (eg Povidone-iodine, Savlon, Chlorhexidine in alcohol, and hydrogen peroxide) should never be used on clean wounds, and should preferably not be used 561

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at all, even for dirty, infected wounds. Antiseptics remove bacteria from wounds but damage fibroblasts, macrophages, capillaries and other cells found in wounds. The result of this is delayed wound healing. Only sterile water or 0.9% sodium chloride should be used for the care of clean surgical and other trauma wounds. Specific management for contaminated and infected wounds will depend on the state of the wound, the extent of contamination and the severity of wound infection. Debridement

To remove necrotic tissue and slough from wounds, debridement is done surgically or by using specific wound products that dissolve slough. Wound healing is promoted by the removal of slough and necrotic tissue, and the risk of wound infection is decreased. Surgical debridement involves the cutting away of slough or necrotic tissue under sedation or general anaesthesia, depending on the extent of the wound and the amount of slough that must be removed. Burn patients are taken to theatre for debridement as soon as their condition is stabilised. During wound care, the nurse may use sterile scissors to remove a small area of necrotic tissue. This must be done carefully to prevent injury to healthy tissue. Closure with sutures, surgical staples or surgical tape

The purpose of skin closure is to promote wound healing and to minimise scar formation. Closure may be achieved using sutures, clips, surgical staples or wound closure strips. • Sutures. Absorbable and non-absorbable sutures are used. Absorbable sutures are used in the deeper tissue layers, where removal will not be possible or necessary. Non-absorbable sutures are used on the body surface, and must normally be removed within 7–10 days after suturing. Sutures may remain in for a shorter or longer period, depending on the position, type of wound and material used for suturing. • Surgical staples and clips. Surgical staples and clips are made of non-reactive stainless steel. This ensures rapid, airtight closure of wounds on the body surface. Removal is as for sutures, even though this can be done much earlier. • Skin closure strips. Skin closure strips are used to close small superficial wounds. The strips are not removed during wound care, but remain in place until the wound is healed. Wound dressings

Different dressings are used for specific wounds: • Moist wound management. Wounds epithelialise in half the time if they remain moist and are prevented from drying out. Continuous cleaning, dressing and application of antiseptic ointments to wounds can hinder wound healing. Clean wounds must be covered with an ideal dressing and left to heal. • The ideal dressing. The ideal dressing should be used according to the needs of the patient. Costs and the condition of the patient’s wound must be taken into consideration when dressing products are chosen. The ideal dressing has the following characteristics: –– Is non-adherent –– Promotes moist wound healing –– Is impermeable to bacteria 562

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–– –– –– –– –– ––

Allows gaseous exchange Is non-toxic and non-allergenic Absorbs excess exudates Is comfortable Protects the wound from injury Does not cause injury to the surrounding tissue.

A great variety of dressings can be used to promote moist wound healing: • Films: These are used to cover the wound and are left in situ for as long as possible. They are removed and reapplied only if they should leak (Tegaderm, Opsite). • Dressing with foams: These dressings have high absorption ability. They are applied and left in position, being changed only when saturated with exudate. • Hydrocolloids: These dressings are used on wounds with light to moderate exudate. These should be left in position for as long as possible, being changed only if there is a leakage. • Hydrogels: These dressings absorb excess exudates while rehydrating necrotic tissue. • Hydrophilic bead: This type of dressing pulls the exudates from the wound into the beads. It should be changed daily. • Alginates: This type of dressing is used on wounds with high exudate production and should be changed when all fibres are saturated. Skin grafting

Skin grafting is a method of closing large traumatic wounds and burn wounds where there has been extensive tissue loss to minimise scar formation. Skin used for the grafting is removed surgically from a healthy non-injured body part. Principles of management for skin-grafted wounds include the following: • Wound dressings are kept moist with sodium chloride 0.9% or sterile water. • Wounds may not be open for five days or longer. • Movement of the body part must be limited. Medication

Systemic and/or local antibiotics, analgesics and anti-inflammatory medication may be prescribed for a patient with a wound: • Antibiotics if wound infection is present • Analgesics to manage pain • Anti-inflammatory medication to reduce inflammation.

Wound complications The complications of wounds are described below. Pain

Pain is the most common complication in the patient with a wound. Patients must be assessed regularly and optimal pain management instituted. Pain is most often caused by infection or improper immobilisation of the injured part. 563

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Haemorrhage

This is a common complication in acute wounds, but also occurs in infected ones. The amount of blood loss must be assessed and, if the blood loss is more than is considered normal, this must be reported to the medical practitioner. The vital signs of the patient must be monitored for signs and symptoms of anaemia and shock. Wound infection

Wound infection is a serious complication and financial costs to a patient can be high due to the following: • Prolonged hospitalisation • A need for antibiotics and analgesics • Doctor’s consultations and hospital visits • Necessary wound-care products • Loss of workdays • Daily travel to hospital by the family if hospitalised or by the patient if dressings have to be done at the health facility. Another complication of wound infection is the health risk to a patient: • Infection is a serious health risk. Septicaemia and septic shock may develop. • Psychological problems may arise due to prolonged illness and increased scar formation. Dehiscence

The term ‘dehiscence’ applies to stitched wounds. Dehiscence means that the wound breaks down and the wound edges separate, exposing the underlying tissue. Wound infection is usually present if a surgical wound dehisces. Dehiscence is more likely to occur in the following circumstances: • If too much pressure is exerted on the new wound • If the patient is obese • If wound infection is present • If stitches or clips are removed too early. Eschar tissue formation

Eschar tissue is hard, non-stretchable necrotic tissue resulting from a thermal or chemical burn. If this tissue surrounds a limb or body part, this may cause impaired capillary blood flow and ischaemia. It is important to assess the circulation to the area of injury if eschar tissue is present. Severe scarring or keloid formation

Severe scarring and keloid formation are complications of large, open traumatic wounds and burns. Assess the patient for psychological/self-image problems. Surgery may be carried out to remove unsightly scar tissue. Hypertrophic scar tissue tends to return. Non-healing

Wound healing must be assessed during wound care. Non-healing must be reported to the doctor, and the cause determined. Patients should be assessed for wound infection, arterial insufficiency, venous stasis and malnutrition. 564

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Chapter 25  Skin integrity need

Conclusion The skin, being the largest organ in the body, serves not only to protect and preserve the structures under it but also determines the psychological expression and personality of individuals. Loss of skin integrity, be it by disease or trauma, or temporary or permanent in its duration, places a lot of stress on the individual. Skin conditions or scars on the body are unsightly, and people with a skin disease or scar (especially in the exposed areas of the body, ie face, arms and legs) tend to be shy and withdraw from society, and society also tends to consider all skin disease as contagious based on the way the skin looks, even when this is not the case. The treatment also is protracted, and requires patience and compliance. In many instances, patients do not comply with this tiresome treatment and often end up with lifelong disfigurement, which can result in serious psychological problems, hence it is important for communities to be taught about how to keep their skin healthy and natural.

Suggested activities for students Activity 25.1 • Students are to visit the surgical wards in the institution and each student must identify a patient with a wound acquired through trauma, a surgical wound or a burn wound. • Students in groups of five (depending on the number of students) are to write out the presentation of the patient in relation to the identified wound in a case format, describing the wound in relation to skin integrity, its nature and factors that affect the healing or non-healing thereof, as well as the prognosis of the wound. The students must also talk to the affected patients about how they feel about the management of the wound and the foreseeable outcome, such as hospital stay, employment aspects, the healing process, scars, contractures, etc. NB! The case is to be presented in class, taking into consideration the ethics of wound care, medico-legal hazards and the nursing implications thereof.

Activity 25.2 The importance of the skin and of skin integrity cannot be emphasised enough. Mrs Nkosi, an elderly lady, has been sick and bedridden for some time. She has been cared for at home. She is brought to the clinic by her grandchildren, who have been doing a very good job of looking after her at home. On examination, the skin on her back and on the heels of her feet is red and tender, her tongue is furred and her nutritional status is borderline. • What are the implications of this scenario for the health of this patient? • What are the ethical considerations in the assessment and management of this patient?

Activity 25.3 Students are to conduct a class debate on the subject: ‘Nutrition and skin health’.

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Hygiene and grooming needs

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate competency in providing for the hygiene and grooming needs of patients under his or her care taking into consideration the patient’s health status, age and culture.

Key concepts and terminology Cerumen: Earwax. Dentures: Dental restorations. Odour: Smell. Sordes: Dry, caked dirt around the mouth composed of saliva, serum from sores and epithelial cells. Talons: Hard, long claw-like nails. Unkempt: Not groomed.

Prerequisite knowledge The nurse should have knowledge of the following: • Basic structure and function of the skin • Microbiology and parasitology.

Medico-legal considerations The scope of practice of registered nurses authorises them to carry out the following, related to the maintenance of hygiene: • The promotion and maintenance of hygiene and physical comfort. Nurses may use a variety of skills to fulfil these provisions, depending on their level of knowledge and expertise. These could include the following: ➙ • Bathing of patients, both adult and infant

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• Hygiene of special areas, ie perineum, anal area, hair, nails, mouth, nose, eyes and ears. Special attention would include the prevention of falls, exposure, chills and burns.

Key ethical considerations • Hygiene is a fundamental aspect of nursing care. Ensuring the hygiene of a patient is related to a nurse’s obligation to provide an environment and circumstances that are conducive to healing and recovery. • Patients are entitled to request services from the nurse, within reason. It is therefore unethical for a nurse to disregard a patient’s requests for a bedpan or urinal, and assistance with washing or with cleaning of teeth. The nurse should also not delay unreasonably in fulfilling these needs of the patient. • The maintenance of the dignity and privacy of the patient is essential, especially during bathing when the body is exposed. The nurse should ensure that the patient is not exposed unnecessarily.

Essential health literacy Both patients and the general public alike should be educated regarding skin care, hygiene and grooming, including the treatment of common problems such as lice, acne, pruritis, dry flaky skin and sunburn (see Chapter 25). The principles of maintaining hygiene in an individual who is ill or disabled are universal and should be applied no matter where the patient is being cared for – whether at home or in a healthcare institution. All individuals caring for sick people must be taught how to carry out the tasks related to hygiene and grooming. Caring for the hygiene and grooming of a sick individual in the home does not necessarily require special equipment, but caregivers may need to be shown how to adapt household items for these tasks. Mothering is an acquired skill and most first-time mothers appreciate being shown how to bathe and change their babies.

Nursing implications • Negligence with regard to ordinary infection control measures, for example sharing of washing towels; incorrect handling and disposal of dirty linen; failure to wash hands between patients, and before and after performing nursing activities, and the inadequate hygiene of baths, toilets, urinals • Disregard of patients’ requests for help to maintain hygiene • Failure to give proper care to back and pressure areas • Failure to observe abnormalities such as skin discoloration or injury • Failure to note changes of venous circulation, skin hydration, loss of sensation and other abnormal conditions including emaciation.

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Introduction One of the fundamental aspects of nursing involves ensuring that a patient’s environment is safe, therapeutic and pleasant. Proper hygiene and grooming of a patient not only contributes to the comfort of the patient, but also helps to ensure that the bed and the immediate environment are conducive to healing and recovery. The purpose of this chapter is to emphasise the importance of hygiene in the nursing care of patients. Nurses will be encouraged to develop an understanding of the concept of hygiene and the factors that affect hygiene and grooming. They will be assisted to become competent in the assessment of their patients’ hygiene and in the identification of problems that will affect their patients’ ability to maintain their own hygiene and grooming. Nurses will also be assisted to become proficient in the skills and techniques used to maintain the hygiene of patients. They will thus be in a position to develop effective care plans for patients with altered hygiene, or the inability to maintain hygiene and grooming, including the evaluation of care and the monitoring of patient progress.

The meaning of hygiene The term ‘hygiene’ refers to cleanliness of the body and of the environment. For health workers the terms ‘hygiene’ and ‘grooming’ are frequently used synonymously, with specific reference to the cleanliness and care of the body. Hygiene and grooming include the cleanliness and care of the skin, hair, nails and genitalia, and also the mouth, teeth, ears and eyes. Grooming refers to the way in which individuals attend to their appearance and how they present themselves in public. It is a much broader concept, which includes hygiene but also extends to the way an individual dresses, does his or her hair, and adorns the face and body. Personal hygiene is a highly particular matter determined by individual values and practices. Hygiene and grooming are influenced by a number of factors, both environmental and cultural. Cultural practices that influence hygiene and grooming are varied, and the basic guideline is to ask a patient what the correct practice is according to his or her culture. Provided that the basic rules of asepsis or prevention of cross-infection are adhered to, the cultural practices of the patient should be accommodated. For example, a Muslim patient will want to wash his or her perineal area after defecation. In some cultures, body hair is acceptable and the individual is not expected to remove it, whereas in other cultures all visible body hair is removed. Frequency of washing also varies from group to group, and this factor is commonly influenced by the climate of origin. For example those who have been brought up in a hot climate will usually expect to have a full bath, shower or full body wash every day. Early socialisation in infancy and childhood also plays a strong role in the forming of the individual’s hygiene and grooming habits. A small child taught to wash and groom in a certain manner will preserve those teachings for a lifetime. Patients who are very ill are often unable to bathe or brush their teeth themselves, or they simply lack the energy to carry out these tasks. Such patients, whether in a hospital or at home, will need the help of a nurse to carry out the basic tasks of hygiene and grooming. A patient’s mental state may also influence hygiene. A depressed individual will often become dirty and unkempt. Conversely, one of the first signs that a depression is 568

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lifting is a re-awakening of the patient’s interest in caring for his or her hygiene and appearance.

Nursing assessment of hygiene and grooming A systematic head-to-toe assessment is needed in respect of a patient’s general state of hygiene and grooming. During the assessment, the nurse should note all aspects pertaining to the hygiene and grooming of the patient. In addition to assessing the patient’s hygiene, the nurse should be aware of the patient’s attitude toward his or her own cleanliness and own individual hygiene and grooming habits. The purpose of assessment is also to collect information about a person’s ability to maintain his or her own personal hygiene. Factors to be borne in mind and which may influence an individual’s personal hygiene regime are described below: • Gender. In general, women are expected to be more fastidious about personal hygiene and grooming than men. A faint whiff of body odour is seldom remarked upon in a man, but is regarded as unacceptable in a woman. Women have long been accustomed to caring for their complexions with a variety of creams and lotions, whereas men have only recently begun to use moisturisers and face masks, and even then will seldom admit to the practice, regarding it as being unmanly. • Stage of development. In young children, the daily habits and routine of personal hygiene and grooming have not yet become second nature, and their hygiene still requires adult supervision. Many children, especially boys, go through a stage in which they positively revel in being dirty, and they may resist washing. Teenagers may sometimes go through a phase during which they neglect personal hygiene and grooming; conversely some teenagers become obsessed with personal hygiene and are overly fastidious. By the time adulthood is reached, an individual should have settled into a definite basic pattern as regards hygiene and grooming. • Environmental factors. Factors such as privacy and the availability of piped water and bath and shower facilities will have an obvious effect on a patient’s personal hygiene. Nurses must always make allowances for such circumstances. • Economic factors. Some patients may lack the means to do more than wash themselves regularly. Very poor patients may be unable to afford good hair care, or may be unable to care for their clothes. Many very poor individuals are forced to put on a hodgepodge of clothing items that they have managed to scrounge or have rescued from the rubbish dump. • Climate. A hot climate usually makes a daily bath or shower mandatory in order to wash away perspiration and accompanying odours, whereas in some cooler climatic areas a weekly bath is regarded as being quite sufficient. • Occupation. People’s occupation has a definite influence on hygiene habits. Individuals who do physical labour, and who get very dirty and sweaty during the course of a day’s work, often shower and change clothes before they go home, or shower as soon as they arrive home after work. Office workers, on the other hand, do not necessarily need to bath or change their clothes immediately after work, and work clothes can double as town clothes or even as going-out clothes. • Culture. As mentioned previously, culture has an important influence on hygiene and grooming. Nurses must ascertain their patients’ cultural background during the 569

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assessment. Religion is also frequently an important influence, and many religions prescribe certain methods of washing for specific occasions. For example, Orthodox Jewish women are expected to take a ‘mikveh’ or ritual bath each month after menstruation. • Individual habits. A patient’s personal routine includes factors such as time preference for bathing, whether morning or evening. This routine also embraces skin care routines and rituals, frequency of hair washing, shaving, and many other activities. Once the specific factors that impact upon a patient’s personal hygiene and grooming practice have been ascertained, the nurse must carry out a physical inspection to determine the actual state of the patient’s hygiene.

Skin • Note the general condition and cleanliness of the skin. Ingrained dirt on exposed areas of the body may indicate an outdoor occupation, but may also be seen in homeless persons who are living outdoors. Skinfold areas such as the groin and under the breasts should be inspected: excoriation in these areas is frequently seen in individuals who have diabetes mellitus. Skinfold areas should also be inspected carefully for parasites, such as lice, which like to congregate in warm, moist areas of the body. If a patient is wearing an appliance such as a corset or braces, the condition of the underlying skin should be examined frequently to identify abrasions early. • Note whether the skin is dry or moist. • Note any lesions or blemishes. Hands and nails • Ascertain the cleanliness of both hands and nails. Dirt under the fingernails may be due to a patient’s occupation and is not necessarily an indication of poor hygiene. Many smokers develop a yellow nicotine stain between the index finger and the middle finger, and the presence of such a stain definitely tells the nurse that the person smokes. • Examine the condition of the nails. Nails that are bitten may indicate chronic anxiety, or nail biting may simply be a bad habit. Ragged, poorly trimmed toenails can be a hazard as they may catch on socks and stockings, and may also press against other toes, causing ulcers. • Give the toenails special attention in the elderly, as the thickened, horny toenails of old age can be very difficult for a patient to trim unaided. When such toenails are left to grow, they easily become long claw-like talons that twist and wrap themselves around the toes. Once this has happened, the offending toenails are extremely difficult to trim or fit into a closed shoe or slip-on. • Try to determine the patient’s hand-washing routine to ensure that this practice is entrenched in the patient’s habits. Hair • Observe the style and length of the hair as this gives an indication of the care the patient takes with his or her appearance.

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• Examine the condition of the hair itself. Dry, fly-away hair may indicate a lack of attention to conditioning and general care of the hair, but dry hair may also indicate poor nutrition. Hair that is greasy and smelly is not well cared for and is not being washed often enough. Inspect the hair for dandruff, as well as for the presence of head lice. Note areas of baldness. In men, baldness is usually normal, but bald patches may also sometimes be seen in elderly women. • Ask the patient about her or his hair-washing routine.

Mouth and teeth Oral hygiene is a very important aspect of general hygiene and basic care. Most individuals maintain adequate oral hygiene through brushing the teeth and rinsing the mouth twice a day. However, in a hospitalised patient and or an ill patient being cared for at home, oral hygiene can become a problem and a source of complications. • Examine the general condition of the patient’s mouth and teeth, looking for any obvious problems. Normally the mouth should be moist and the tongue a bright pink colour. • Note furring of the tongue, as well as the presence of white plaques on the tongue. White plaques may be patches of oral thrush, which is often seen in an immunocompromised patient, and in a patient who is taking steroids. A furred tongue is frequently seen in an ill patient who is not eating and drinking adequately. • The odour of the breath, if any, should be noted: –– A foetid odour is detected where oral hygiene is poor. –– A ‘dead mouse’ smell is detected in liver disease. –– A sweet smell or an odour of apples or nail varnish remover indicates the presence of ketones and suggests poorly controlled diabetes mellitus. The condition of the teeth should be examined. The presence of dental caries in the mouth must be noted, as well as excessive plaque around the teeth: this indicates poor oral hygiene, but may also be seen in very poor patients who cannot obtain good toothbrushes or dental floss. Swollen red gums indicate gingivitis. Note whether the patient wears any form of dentures or bridge. Ask the patient about his or her tooth-cleaning routine.

The eyes In a healthy individual, hygiene of the eye is seldom a problem, and it is not often that individuals have a specific routine for eye care. The eyes normally take care of themselves. However, in poverty-stricken communities where environmental hygiene is lacking and the nutritional status of the community is deficient, sticky eyes with matted lashes are encountered, especially in young children. Such children go on to develop chronic irritation of the eyes, leading to visual problems later in life. In assessing the hygiene of a patient, therefore, the nurse should look at the condition of the eyes, eyelids and eyelashes, noting any encrustations. Styes or small abscesses of the eyelashes are frequently seen in poorly nourished or immuno-compromised patients. Chronically red eyes are often an indication of eyestrain, and the patient should be advised to have his or her eyes tested.

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The genitalia When assessing hygiene it is essential to examine the genitalia, as several important clinical problems can be detected by a simple assessment of the condition of the genitalia: • Examine the general state of cleanliness of the genitalia. The skin should be pink and moist, and should appear clean. A faint musky odour may be detectable, which is normal. Excessive secretions caked in the skin folds may be an indication of inadequate hygiene. • Note any offensive odour or discharge from the urethral meatus or the vagina in women, as this usually indicates infection. • Note any white patches on the labia in women or under the foreskin in men, which may be due to thrush. Thrush may be due to diabetes mellitus or it may indicate candidiasis (or moniliasis) in an immuno-compromised patient with a condition such as HIV/AIDS. • Note a red, excoriated groin and vulva. This may be seen in elderly women who are diabetic. The irritation is due to the presence of sugar in the urine, of which some remains on the skin of the vulva after voiding. Meticulous hygiene of the area as well as control of the diabetes is required to resolve the problem. • Note any lesions or sores, and report these promptly. Sores and lesions on the genitalia are invariably an indication of the presence of sexually transmitted disease(s), and the sooner the patient is investigated and treated, the better for both the patient and his or her sexual partner/s.

Common clinical problems Maintenance of hygiene and grooming in patients unable to help themselves Daily hygiene and bathing are an important aspect of basic nursing care. Bathing the patient removes perspiration, which may increase in some illnesses, accumulated oil, dead skin cells and some bacteria. A warm bath also stimulates the circulation – it is soothing and relaxing for the patient. A daily bath also affords the nurse an excellent opportunity to assess the patient as the patient’s body is exposed. During the daily bath, the nurse should not only bath the patient, but should also carry out basic grooming tasks such as the brushing of hair, shaving in men, and applying deodorant or aftershave lotion. These actions will make the bath not only refreshing for the patient but will improve her or his morale, appearance and self-respect. The daily bath

• Patients who are unable to help themselves need to be washed by the nurse or, if the patient is able, the patient should be assisted to wash by the nurse. The dignity of the patient must always be maintained, and exposure of his or her body must be minimised. While protecting the bedclothes with towels, the nurse exposes and washes each limb or area of the body separately, beginning with the face and ending with the genitalia. If the patient is able, he or she may prefer to wash the genitalia unaided. The nurse should, as far as possible, follow the patient’s own practices, for example using soap on the face or not, or using separate washcloths for face and body. While washing the patient, the nurse should also take the opportunity to 572

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apply face and body creams, deodorant, aftershave or talcum powder, taking care not to apply too much powder as it may become caked in skinfold areas and cause irritation.

Figure 25.1  A bed bath • Men who are normally clean-shaven should be shaved at least every other day. Nothing looks more unkempt and uncared-for than a man whose beard area has been neglected. When using a razor to shave a patient’s beard, apply shaving cream or shaving soap and water first to soften the bristles and make the skin more pliable. Hold the blade at a 45º angle to the skin and shave in short, firm strokes in the direction of the hair growth. Hold the skin taut, particularly around creases, to prevent cutting the skin. After shaving the entire area, wipe and wash the patient’s face with a wet facecloth to remove any remaining shaving cream and hair. Dry the skin well, then pat aftershave lotion on with the fingertips or apply powder in accordance with the patient’s preference. The beard of those men who do not shave should be kept trimmed and clean. A beard or moustache may not be shaved off without the patient’s consent, unless removal of the beard is essential for treatment and care, as, for example, if a tracheotomy tube is in situ. • During the bath, skinfold areas should receive special attention and should be dried well, as these areas become irritated if left damp. The nurse should also pay particular attention to the area under the breasts in women who are obese or who have large breasts. • After bathing the patient, it is usual for the nurse to refresh the patient’s bed linen, or to change it entirely. If the patient is bedridden, the nurse moves him or her from side to side, or up and down in order to change the bottom sheet and draw sheet. Depending on the condition of the patient, he or she may be seated on a chair while the nurse changes the bed. • During the daily bath the nurse should clean under the patient’s nails and trim them if necessary. Place a kidney bowl or bath towel under the hand, and cut the nail or file it straight across beyond the end of the finger or toe. Avoid trimming or 573

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digging into nails at the lateral corners on the toes, as this predisposes the patient to ingrown toenails. Patients who have diabetes or circulatory problems should have their nails filed rather than cut. • The daily bath is an ideal opportunity for the nurse to give individual attention to the patient, to talk to him or her, and to develop a good nurse–patient relationship with the patient. • To maintain the condition of the hair, it should be brushed daily, particularly if it is long, as long hair mats and tangles easily if the patient is confined to bed. Dry shampoo can be used to reduce greasiness in the hair of a patient who is confined to bed, but it is usually preferable to actually wash the hair. Hair washing

Washing the hair of a patient in bed can be quite an undertaking. A fairly easy way to do this is as follows: • Pull the bed away from the wall. • Pull the mattress down to expose enough of the spring to rest a basin on. • Where possible, shift the patient up in the bed until the head is at the top edge of the mattress if possible with the hair hanging over the edge (with the patient facing up). • With the patient thus positioned, a basin can be placed on the exposed spring to make a backwash, and the hair is then washed using a jug and basin. Obviously the bedclothes must be protected with towels or a plastic sheet while the hair is being washed. After washing, the hair should be towelled and dried well, using a hairdryer if possible.

Figure 26.2  Washing a patient’s hair • African hair that has not been straightened or styled in any way does not usually tangle and will normally remain tightly curled and close to the head, but the hair does need to be conditioned from time to time, as it tends to be dry and brittle. African hair should be gently combed every day using a wide-toothed ‘Afro’ comb. Braided hairstyles should simply be left in place and can be washed as is. Do not 574

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undo braided hair without the patient’s permission. After washing the hair, it should be towelled and dried well, using a hairdryer if available.

Hygiene of the eyes, ears and nose Eye care

Dried secretions that have accumulated on the eyelashes need to be softened and wiped away. • Soften dried secretions by placing a sterile cotton wool ball moistened with sterile water or normal saline over the lid margins. • Wipe the loosened secretions from the inner canthus of the eye to the outer canthus to prevent the particles and fluid from draining into the lacrimal sac and nasolacrimal duct. • If the patient is unconscious and lacks a blink reflex or cannot close the eyelids completely, drying and irritation of the cornea must be prevented. Lubricating eye drops may be administered if ordered by a physician. The eyes of an unconscious patient should be kept closed to protect the cornea: this can be done by means of eye pads, or by gently taping the eyes shut with a non-irritant tape. Contact lens care

Contact lenses may be hard, soft or gas-permeable lenses. Most patients normally care for their own lenses. They learn a care method that best suits them from their eye specialist. Seriously ill patients whose contact lenses have been removed will not need them reinserted until they have recovered. If the patient is unconscious and is known to be wearing contact lenses, these should be removed. If the nurse is unable to remove them, an ophthalmologist should be called in. Once removed, the lenses should be kept safely or sent home with the patient’s family. Artificial eyes

Artificial eyes are usually made of glass or plastic. Some are permanently implanted, while others are removed regularly for cleaning. Most patients who wear a removable artificial eye follow their own care regimen. Even for an unconscious patient, daily removal and cleaning is not necessary. If the nurse notices problems – for example redness of the surrounding tissues, drainage from the eye socket or crusting on the eyelashes – or if the patient is scheduled for surgery, the nurse must remove the eye from the socket; clean the eye, the socket, and the surrounding tissues; and then re-insert the eye. Patients whose mobility is impaired by injury or paralysis may also require assistance. In addition, the nurse must determine the patient’s routine eye care practices so that these can be followed. Some patients may remove and clean the eye and socket daily. General eye care

Avoid home remedies for eye problems, such as rinsing the eyes with urine to treat a sty. A patient should not try to remove a foreign body at home. If dirt or dust gets into the eyes, they should be cleaned with plenty of clean, tepid water or saline as a first step. If the irritation persists, a medical practitioner should be consulted.

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Ear care

Normal ears require minimal hygiene. Patients who have excessive cerumen (earwax) and dependent patients who have hearing aids may require assistance from the nurse. The auricles of the ear are cleaned during the daily bath. The nurse or patient must remove excessive cerumen that is visible or that causes discomfort or hearing difficulty. Visible cerumen may be loosened and removed by retracting the auricle downward and the cerumen extracted with a dissecting forceps. Patients need to be advised never to use hairpins, toothpicks or cotton-tipped buds to remove cerumen. Hairpins and toothpicks can injure the ear canal and rupture the tympanic membrane, and cottontipped buds can cause wax to become impacted within the canal. Hearing aids

Hearing aids must be removed before surgery. To ensure proper functioning, the patient must handle the hearing aid appropriately during insertion and removal, clean the earmould regularly and replace dead batteries. Nasal care

Excessive nasal secretions can be removed by inserting a cotton-tipped bud moistened with water or normal saline or by applying suction. A cotton-tipped bud should not be inserted beyond the length of the cotton tip. The nares of patients with nasal tubes should be cleaned with a moistened cotton-tipped bud to prevent the accumulation of secretions around the tubing. The tape that anchors the tube should be changed when it becomes moist to prevent maceration of the skin and mucous membrane.

Oral hygiene and mouth care Normal care

Where possible, maintain a normal oral care routine and ensure that the patient’s teeth and mouth are kept clean by means of brushing. Commercially available toothpaste can be used, or an effective dentifrice can be made by combining two parts of table salt to one part of baking soda. When cleaning the teeth, the sulcular technique (see box on the next page) should be used, as this is the most effective way to clean the teeth and remove plaque. Flossing of teeth is especially beneficial in preventing the formation of plaque and removing it from the teeth, particularly at the gum line. Care of dentures

If a patient is incapacitated, elderly, confused or confined to bed, care of dentures becomes the nurse’s responsibility. • Wear gloves to remove dentures and, using a piece of tissue or gauze to prevent slipping, grasp them at the front with the thumb and index finger and slide them out of the mouth. • To remove lower dentures, first pull the cheek back, and then turn the denture slightly and remove by pulling it out between the lips, one side at a time. Partial plates and removable bridges may also need to be taken out by the nurse.

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The sulcular technique • Moisten the bristles of a soft toothbrush with tepid water, and apply the toothpaste or dentifrice. • Hold the brush against the teeth with the bristles at a 45º angle. The tips of the outer bristles should rest against and penetrate the gingival sulcus. The brush will clean under the sulcus of two or three teeth at one time. • Move the bristles back and forth using a vibrating or jiggling motion, from the sulcus to the crowns of the teeth. • Repeat until all outer and inner surfaces of the teeth and sulci of the gums are cleaned. • Clean dentures with a toothbrush, a dentifrice or toothpaste, and tepid water. Hot water is not used because heat may change the shape of some dentures. Rinse the dentures well and replace them in the patient’s mouth.

Clinical alert! A legendary mistake that could be made by an inexperienced nurse is to collect the dentures from all of the patients in a hospital ward and then place them in a single container for cleaning. To match up dentures and patients, the nurse would have to try the dentures in each of the patients for size. Dentures must be removed and cleaned one patient at a time.

If dentures are stained, soak them in a commercial cleaner, following the manufacturer’s directions. To prevent corrosion, dentures with metal parts should not be soaked overnight. Before re-inserting dentures, observe the dentures for rough, sharp or worn areas that could irritate the tongue and mucous membranes of the mouth, lips and gums, and inspect the patient’s mouth for any redness, irritated areas or indications of infection. Unconscious and seriously ill patients

Mouth care for unconscious or very ill patients is very important, since their mouths tend to become dry, or the lips, gums and tongue become coated with a combination of saliva, micro-organisms and epithelial cells known as sordes. A dirty or dry mouth is predisposed to infection. Dryness in the mouth occurs when the patient cannot take fluids by mouth or is breathing through the mouth or is on oxygen therapy, which tends to dry the mucous membranes. The mouth of an unconscious or helpless patient is cleaned using cotton wool balls or gauze squares, or commercially made applicators. All the surfaces of the mouth are wiped clean, and any solids are gently removed. Some nurses advocate cleaning the mouth using a toothbrush and toothpaste and then rinsing with a mouthwash, which is then removed using suction. Other preparations that may be used to clean the mouth include lemon juice mixed with oil, sodium bicarbonate and plain mouthwash.

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Genital hygiene • The genital area is a moist dark place where bacteria may thrive if proper hygiene of the area is not maintained. Although a nurse may find this task embarrassing, it is a vital task, especially if the patient is not able to maintain adequate hygiene of the area. The genitalia should be washed with soap and water, and then dried thoroughly. Some units prefer to use a mild antiseptic, such as Savlon, but this may cause irritation if the mixture is too strong. • In a female patient, the vulval area and the labia majora should be cleaned first, then the labia are spread to wash the folds between the labia majora and the labia minora. For menstruating women and patients with indwelling catheters, use cotton wool or gauze, using a clean cotton wool ball or gauze square for each stroke. • In a male patient, the penis should be washed well and dried. If the patient is uncircumcised, pull back the prepuce (foreskin) to expose the glans penis for cleaning, and replace the foreskin after cleaning. The scrotum should also be washed and dried. The nurse should carefully inspect the area around the urethra in patients who are catheterised to check for intactness of the urethral orifice. Protective ointments can be applied to the urethral area if necessary. The maintenance of hygiene in neonates and infants Daily bathing of a neonate/infant

A daily bath is important for both the caregiver and the baby, as it is an occasion for touching, cuddling and communicating, all of which play an important role in the baby’s development. The daily bath is also an excellent opportunity for the nurse to assess the baby. • The infant’s overall size and shape are immediately apparent, as is the relative size of the head, extremities and trunk. Microcephaly or cranial enlargement is obvious. If hydrocephalus is present, the forehead is often very prominent. • The baby’s posture and the posture of the limbs should be examined. Normal flexion of the extremities indicates good muscle tone. Lack of flexion is associated with flaccidity, whereas excessive flexion usually suggests hypertonicity (spasticity). • Skin colour and condition are observed. Jaundice, pallor, rash, cyanosis and evidence of trauma must be reported and recorded. • The facial expression should be noted. • Evaluation of respiration should be part of the nurse’s overall inspection: at rest a normal neonate breathes at a rate of 30–40 breaths per minute, with no rib retraction or flaring of the nostrils. Following the initial examination, the nurse carries out a simple physical examination of the baby: • Gently palpate the abdomen to detect distension or any obvious masses. • Then palpate the major pulses, and palpate the apical pulse by placing your hand over the baby’s heart. • Gently palpate the vertebral column to feel for any obvious abnormalities. • Examine the genitalia, once again, to detect any obvious abnormalities.

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The normal umbilical cord is bluish-white and moist at birth. Within 24 hours it begins to dry and becomes dull and yellowish-brown. Later it turns black and shrivels considerably. After birth, the cut section of the cord reveals three blood vessels (two arteries and one vein). A single umbilical artery is a reason to search for other congenital malformations of any type. If meconium has not been passed by the end of the first day of life, patency of the anus should be ascertained by inserting the tip of a thermometer or thin catheter for a distance not in excess of 1 cm (this is routinely done with the first bath).

General principles of a baby bath • Prevent cross-infection between babies, and between the nurse and the baby. • Prevent physical injury to the baby through falling or by having the bath water too hot, which will burn the baby. The temperature of the bathwater should always be tested before bathing the baby; a simple way to do this is to use the elbow – the water should not feel too hot to the elbow. The baby must be securely held at all times during the bath – a healthy baby can roll off a counter top in no time at all if not securely held. • Prevent excessive cooling of the baby. • Stimulate the baby by touching and communicating with the baby.

To carry out a baby bath, the nurse proceeds as follows: • First, undress the baby and then securely wrap him or her in a towel to prevent kicking and struggling. • Pick up the baby and tuck him or her under your arm. • Place your thumb and middle finger over the ears of the baby. • Keep the baby’s head over the edge of the washbasin and wet the head and hair with the right hand. • Apply baby shampoo to the head. Massage the head gently with the fingertips. • Rinse the head thoroughly. • Place the baby on the work surface and dry the hair. Give special attention to the neck and behind the ears. • Next, loosen the towel without overexposing the baby. • Use the washcloth or hands to cover the body with soap lather in the following order: –– Anterior neck area, chest and abdomen –– Arms from the pulse joint to the axilla –– Feet and legs, while washing in the direction of the groin –– Turn the baby to the side and wash the back from top to bottom –– Wash the genitalia and buttocks last. • Lift the baby by placing your left hand under the axilla furthest away. The head and neck of the baby must rest on your left lower arm. Place your right hand on the baby’s thighs and lift the legs. • Lower the baby into the washbasin. • Cover the baby’s hands (one at a time) with soap; wash and rinse. 579

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• • • • • • •

Allow the baby some time in the water to play and kick. Lift the baby out of the water in the same manner the baby was placed in the water. Place the baby on the towel and gently dry the baby. Place on side and dry the back. Give special attention to the axilla and groin. Place a nappy under the buttocks. Dress the baby quickly to avoid exposure. Apply petroleum jelly to the buttocks to prevent ammoniac dermatitis before securing the nappy. • Communicate and talk with the baby during the entire bathing procedure. This will make you and the baby feel more relaxed and will enhance a feeling of security in the baby. Changing of nappies

Babies and infants are incontinent until control is established over bowels and bladder by two to three years of age. Until then, the baby needs to be kept clean and dry by the mother or caregiver whenever urine or faeces have been passed. • When the baby is wet or dirty, the nappy should be changed and the buttocks and perineum cleaned. • First, the dirty/wet nappy is removed and discarded. • The perineum and buttocks are thoroughly cleaned using a soft wet cloth, tissues or wet wipes. • Barrier cream or Vaseline can be applied to the buttocks and perineum to prevent nappy rash. • Once the baby is clean and comfortable, put on a fresh nappy.

Conclusion Hygiene and grooming are tasks that individuals perform on a daily basis to indicate self-care and self-respect. Keeping oneself clean is an indication of awareness of surroundings, a need to relate to others, a wish to belong and pride in one’s appearance. The ability to keep clean is also a measure of mental outlook, hence depressed persons may neglect self-care.

Suggested activities for students Activity 26.1 Each student must carry out a bed bath under the supervision of a lecturer and ensure that all aspects of hygiene and grooming are attended to.

Activity 26.2 Each student must carry out a baby bath under the supervision of the lecturer.

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27

Sensation, perception and cognition

Learning objectives On completion of this chapter, the student should be able to do the following: • Accurately assess the patient with a sensory deficit or altered mental status, and interpret assessment findings. • Identify sensory problems such as deafness or blindness. • Use the Glasgow Coma Scale and other parameters to observe a patient with an altered level of consciousness. • Assess physiological causes of confusion, especially fluid and electrolyte imbalances. • Implement nursing interventions designed to maintain optimum sensation, perception and cognition by: –– assisting the visually- or hearing-impaired patient –– ensuring the safety of the environment for patients with visual impairment –– communicating with hearing-impaired patients –– making appropriate use of aids to vision and hearing –– managing confused and/or disoriented patients, and maintaining continuity of care in the face of confusion and agitation –– ensuring the safety of the confused patient. • Manage unconscious patients and meet their needs.

Prerequisite knowledge The nurse should have knowledge of the following: • Comprehensive assessment of the patient • Anatomy and physiology of the special senses • Recording data and reporting of deviations from the normal data.

Key concepts and terminology Balance: The ability to maintain the position or equilibrium of the body. Co-ordination: The ability to control movement.

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Higher cognitive functions: Learning, memory, problem solving, abstract thinking and creative thinking, among others, by utilising the information gleaned from the environment by means of the senses. Level of consciousness: The degree of awareness and responsiveness demonstrated by the patient. Mental state: The individual’s orientation, emotional state and level of consciousness. Motor function: The ability to move all movable body parts normally. Reflexes: Involuntary motor responses to a stimulus. Sensory function: The ability to perceive the environment through the senses of vision, hearing, touch, taste and smell. Unconsciousness: A state in which the individual lacks awareness and is unable to respond to the environment.

Key ethical considerations • Nurses must act as advocates for patients who are confused or unconscious, and who cannot speak for themselves. They must ensure that the rights of these patients are not disregarded. They also have an obligation to take due care in respect of the care of vulnerable and helpless patients. • Nurses must always ensure the maintenance of every patient’s dignity. Behaviour and speech that is disrespectful must be avoided, especially in the case of a confused patient. Nurses should never tease such patients, but should rather try to re-orientate them to reality by constantly reassuring them and telling them where they are and what is happening around them. • Nurses should take care with what is said within hearing distance of an unconscious patient. The sense of hearing is not necessarily lost during unconsciousness and the patient may remember what has been said afterwards. • Nurses should always explain actions and procedures to patients, even if they do not appear to respond or understand. • The next of kin should be involved in decision making in relation to the care of confused or unconscious patients. • Proper ethical decision-making processes should be followed.

Medico-legal considerations • Registered nurses are authorised to carry out a nursing regimen designed to meet all the biological and psychological needs of patients suffering from a deficit of sensation, perception or cognition. • Nurses may use a variety of skills to fulfil these provisions, depending on their level of knowledge and expertise.

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Health education aspects • Visually impaired patients should be oriented to the environment. • Confused patients should be constantly re-oriented to reality and to the environment. This provides a frame of reference that may help to alleviate their confusion. • The preservation of vision and hearing is an important aspect of healthcare and health education in the community. Factors essential for the preservation of vision include the following: –– A balanced diet containing all essential nutrients and vitamins, especially vitamin A –– Prompt treatment of any eye infections or irritations –– Regular testing of vision, especially in schoolchildren, in order to detect refraction problems that will require spectacles – poor vision may severely hamper a child’s progress at school –– Avoidance of substances that may irritate the eye –– Protecting the eye from bright sunlight –– Protection of the eyes in industry – procedures such as welding may damage an unprotected eye. • Factors essential for the preservation of hearing include the following: –– Education of individuals and the community at large about the detrimental effects of noise pollution. Over time, prolonged exposure to high levels of noise may result in the impairment of hearing, particularly in the middle tone ranges. –– Education of mothers not to prop feed bottle-fed infants. When this is done there is a possibility that some of the feed may run into the Eustachian tubes and cause an infection of the middle ear. –– Prompt attention to ear infections in infants and young children. Inadequate treatment may lead to hearing problems later in life. –– Discouraging individuals from inserting sharp objects into the external auditory meatus, as this may damage the eardrum. Usually the external ear is self-cleaning; any excess wax build-up should be removed using warm oil, which will soften and loosen the wax. Severe cases of wax build-up may result in conductive deafness and should be treated promptly by a medical practitioner or a qualified health worker. –– Cleaning of the ears of infants using a soft damp cloth, and only the external portion or pinna should be cleaned, not the meatus. Ear buds are potentially dangerous as they may rupture the eardrum and lead to infection. –– Conducting a hearing test as part of the assessment of every child who appears to be slow and behind with school work. Such children may have a hearing defect. –– Correction of the hearing deficit by means of hearing aids, or specialised schooling for the affected children. This can be of immense help to such children, as they can often be disruptive at school due to their frustration.

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Common pitfalls/mistakes to avoid • Any sudden alteration in mental status/level of consciousness is significant and potentially serious. Such changes should always be investigated. In the elderly, confusion is often the first symptom of complications such as pneumonia or cardiac failure. Following surgery in the elderly, confusion and restlessness may be the first sign of internal bleeding. • Always assess a confused patient thoroughly, as confusion is frequently due to problems such as fluid, electrolyte and acid–base imbalance, or hypoxia. Safety is very important: ensure that the cot sides are up when caring for confused, restless or unconscious adult patients and children; ensure safe use of restraints; check lines and catheters regularly. • Never ignore a confused or unconscious patient as accidents may happen very quickly and unexpectedly. Unconscious, restless and confused patients should always be within sight of a nurse. • Do not rearrange the environment of visually impaired patients as objects in unfamiliar places can cause accidents. • Do not mock or tease agitated patients – this may make the confusion and agitation worse.

Introduction The functions of sensation, perception and cognition refer to the ability to receive and interpret information about the environment. This involves the ability to see, hear, feel and smell, as well as the cognitive functions of the brain, which enable an individual to understand information and respond appropriately. Interaction with the environment includes problem-solving skills, the ability to learn and the ability to anticipate the effects of an action based on previous experience. These capabilities involve the higher cortical functions of learning, memory, communication, thought and consciousness itself. Sensory functions, level of consciousness and mental state have significant implications for nursing care. Sensation, perception and cognition enable the patient to perceive the environment and to respond to it. Alterations in these functions impair the individual’s ability to function in his or her environment, and it is important for the nurse to be able to assess the needs of the patient and to be able to plan and implement care for the patient with a deficit of sensation, perception and/or cognition.

The functions of the central nervous system Interpretation of sensory information Sensory information is provided by sensory receptors found in all organs and structures of the body. The brain interprets the information provided by these receptors. It is by means of this steady input of sensory information that the brain is aware of the state of the body and conditions in the outside environment. • Each type of sensory receptor is sensitive to only one type of stimulus. • Irrespective of the type of receptor and the stimulus involved, the sensation that rises to consciousness and is finally perceived by an individual is one that has been analysed and contextualised by the cerebral cortex. 584

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• All somatic sensations (ie sensations from the body) enter the nervous system via the spinal cord. Some sensations are carried by the cranial nerves, bypassing the spinal cord and entering the nervous system at the level of the brainstem. • Incoming sensory information is interpreted in the sensory cortex and the sensory association areas. • The sensory cortex is able to recognise the type of sensation, its location and intensity. • The sensory association area, which receives input from the thalamus as well as the visual and auditory areas of the cortex, enables an individual to fully experience incoming sensations and place these sensations in context, both physically and emotionally. • Sensations of hearing, vision, smell and taste pass directly to the specialised auditory, visual, olfactory (smell) and gustatory (taste) areas of the cortex. These specialised areas have their own association areas that enable information from the special senses to be finely interpreted and placed in context.

Control of motor function Response to sensory stimuli frequently involves bodily activity, although this is not necessarily always the case. An intact motor system is, however, essential for an adequate and appropriate reaction to environmental stimuli. • All voluntary movement begins with a conscious decision in the cerebral cortex. However, many aspects of voluntary movement are carried out unconsciously so that we do not have to think out every movement that we make. • Motor signals are transmitted to the body via the cortico-spinal tracts of the spinal cord. Approximately 75% of these tracts decussate, or cross over, in the medulla oblongata, which means that the right hemisphere of the brain controls the left side of the body, and vice versa. • Indirect motor fibres arise in the basal ganglia, midbrain and cerebellum, and are concerned with the automatic adjustments required for balance, posture, the control of complex movements and the correct sequence, accuracy and strength of movement. Higher cognitive functions The higher cognitive functions of the brain involve learning, memory, problem solving, abstract thinking and creative thinking, among others, utilising the information gleaned from the environment by means of the senses. These higher cognitive functions also include consciousness and the ability to assign meaning to events. The ability to process and analyse incoming information accurately is dependent on the proper functioning of the higher cortical areas, therefore the mental state and level of consciousness are important factors for optimum sensation, perception and cognition.

Nursing assessment of functions related to sensation, perception and cognition In order for a nurse to evaluate the functions of sensation, perception and cognition in a patient, the following areas are assessed. 585

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Assessment of sensory function Adequate perception is dependent upon intact sensation, and a survey of gross sensory function is undertaken. Assessment of vision

For the purposes of undertaking a survey of sensory function, a general assessment of vision is sufficient. If the patient were suffering from a specific ophthalmological or visual problem, specific diagnostic tests would have to be carried out. These are beyond the scope of this level of assessment. When carrying out a general assessment of vision, the nurse aims to determine whether the patient can see well enough to be able to discern the environment. • The nurse should ask the patient if he or she has a visual problem. If the patient does have one, the nurse should ask the patient to describe it in order to find out to what extent the patient’s abilities to read, drive or carry out the activities of daily living are affected. • The nurse should further ask if any medication is being used and if the problem causes any practical problems at home or at work, and if so, how the patient overcomes them. • The nurse should also note the use of aids for vision, such as glasses or contact lenses. • General observation of the patient is also useful, and the nurse should note any details of the patient’s appearance that may indicate that he or she cannot see well. Odd clothing combinations may indicate a problem with colour vision or severe visual impairment. An unusual head position may be adopted in order to see more clearly and alleviate a visual problem. Screwed-up eyes may indicate eyestrain or photophobia. • The nurse should also note the overall appearance of the eyes. The eyes should be symmetrical and normally placed on the face. They should be clear, and be neither bulging nor sunken. An abnormal appearance of the eye is often correlated with a visual problem. Assessment of hearing

As is the case with vision, the purpose of carrying out a general assessment of hearing is to determine whether or not the patient can hear well enough to understand what is said to him or her. A detailed explanation of the diagnostic tests that are undertaken in order to investigate auditory problems is beyond the scope of this chapter. • The nurse should ask about problems such as hearing loss, dizziness and tinnitus (ringing or buzzing in the ears). If the patient has a hearing deficit, the nurse should determine whether the hearing loss was gradual or sudden. • What effect has the hearing loss had on the patient’s life, and what strategies does the patient use in order to cope with the problem? • Does the hearing problem affect the patient’s social life and activities of daily living, and if so, how does the patient cope with this? Does the patient wear a hearing aid or use some other device such as a hearing trumpet?

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• The nurse should assess the patient’s response to a normal speaking voice by asking the patient to answer simple questions. Standing behind the patient when asking questions will eliminate lip reading. • The nurse should also note any obvious problems with the patient’s ears, such as swelling, obvious inflammation or a discharge from the ear. Assessment of other sensory functions

Once again, the nurse carries out a general assessment with the purpose of identifying any major and obvious sensory deficits. Asking the patient whether a light touch of the nurse’s hand can be felt on both arms and both legs does a gross assessment of the sense of touch. Table 27.1  Assessment of sensory function Tactile sensation

Tested by lightly touching corresponding areas on either side of the body with a cotton wool wisp

Pain and temperature sensation

To assess temperature sensation, corresponding areas on either side of the body can be touched with an ice cube followed by a warmed tongue depressor or other metal instrument. Alternatively, test tubes with hot and cold water can be used Determining the patient’s sensitivity to a sharp object (without assaulting the patient) can usually assess pain. A pin is not advisable as it may break the patient’s skin

Vibration and proprioception

Vibration sense is tested by means of a vibrating tuning fork placed against a bony prominence. The forehead is usually used. The patient is then asked if the vibration can be felt and for how long. Both prominences of the forehead should be tested Proprioception is tested by gently moving the joints of the fingers and toes, and determining whether the patient can detect these movements with the eyes closed

Integration of sensation

Testing two-point discrimination and stereognosis assesses higher cortical sensory function. Two-point discrimination is evaluated by placing the ends of two sharp objects on the patient’s skin and asking the patient to state how far apart the two points are with the eyes closed. Are the two objects perceived as being two objects, or are they felt as one object? If the patient is touched on both sides of the body simultaneously, the patient should report being touched in two places. Stereognosis refers to the ability to recognise familiar objects by touch, and this function is assessed by asking the patient to identify familiar objects placed in the hand with the eyes closed.

Assessment of motor function A general assessment of motor function is done in order to determine whether the patient can move all limbs, and to ascertain the patient’s general mobility. 587

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• Muscle tone (whether limp or flaccid) and muscle strength are assessed in both arms and both legs. • Gait, or manner of walking, should be observed, and a note made of any problems. • Ascertain whether the patient uses any walking aids, such as a stick, crutch or walking frame. Table 27.2  Assessment of motor function Muscle strength

• Muscle strength is assessed by testing the ability to both flex and extend muscles and muscle groups against a resistance provided by the assessor pushing against the direction of movement

Balance and co-ordination

• Rapid alternating movements and point-to-point testing are used to assess co-ordination. The patient is asked to turn the hands from pronation to supination as rapidly as possible. Another way of testing co-ordination, specifically that of the lower limbs, is by asking the patient to run the back of the heel down the anterior surface of the tibia • In point-to-point testing, the patient is asked to alternately touch the assessor’s finger and the tip of his or her nose several times • Balance is tested by means of the Romberg test. The patient is asked to stand with feet together and eyes closed, and to hold that position for approximately 30 seconds

Reflexes

• Motor reflexes. Involuntary contractions of skeletal muscles in response to a stimulus. A patellar hammer is used to deliver a light yet firm tap to a muscle or tendon • Biceps reflex. The biceps tendon is tapped while the elbow is flexed. The biceps contracts and there is flexion at the elbow • Triceps reflex. The elbow is flexed and placed in front of the chest. The tendon is tapped 2.5–5 cm above the elbow. The triceps muscle contracts and the elbow is extended • Brachioradialis reflex. The arm should be resting on the lap or on the abdomen. The brachioradialis tendon is tapped 2.5–5 cm above the wrist. The wrist flexes and there is supination of the forearm • Patellar tendon. The tendon is tapped just below the patella. The quadriceps contracts and the knee is extended • Ankle reflex. This is elicited by dorsiflexing the foot and tapping the Achilles tendon. The foot should plantar flex • Plantar reflex. The sole of the foot is stroked with a pen or with the pointed end of the patella hammer. A normal response is for the toes to flex altogether. If the toes extend and fan out, the response is abnormal and is termed a positive Babinski response • Abdominal contraction reflex. Stroking of the abdominal wall will cause contraction of the abdominal wall. In men, stroking of the inner thigh will produce an involuntary contraction of the scrotum.

Assessment of mental state A general survey of the patient’s mental state will reveal orientation, level of consciousness and the ability to understand what is taking place in the environment.

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• The general appearance of the patient should be observed. An unkempt appearance, dirty clothes, poor personal hygiene and poor grooming may be an indication that the patient is not in his or her normal state of mind. • The general behaviour of the patient should be noted. Aggressive, withdrawn or inappropriate behaviour is often indicative of an altered mental state. Observation of gestures, body language and facial expression can also give important clues. • Asking the patient a simple question, such as what he or she ate for breakfast the previous morning, can assess memory. A more objective test is to see if the patient is able to recall recent events, such as news items. The patient can be asked to commit three or four unrelated items to memory and asked to repeat the items a few minutes later. • Asking the patient to state his or her name, as well as the date and time assesses orientation to time, place and person. Asking the patient to state where he or she is and why he or she is there will indicate orientation to place and the reason for being there. • Speech and language also provide important information about a patient’s mental state. The patient’s speech should be clear and coherent. Is the patient able to understand written information, such as the admission form? Is the patient able to write his or her own name, or copy a simple figure drawn by the assessor? • The thought content expressed by the patient should be relevant, logical and appropriate: fixed ideas, illusions or preoccupation may indicate a problem. The nurse should note any evidence of hallucinations or ideas of persecution. • Emotional state is an important component of a mental status evaluation, and the nurse should note any aggressiveness, irritability, excessive anxiety, euphoria or apathy. Excessive fluctuations in mood should be noted. The nurse should also note if the patient’s expressed mood is appropriate to the situation. • An assessment of level of consciousness is an important component of the mental status evaluation. Initially, the nurse assesses the patient’s general level of responsiveness. Is the patient fully conscious, alert and aware of his or her surroundings, or is the patient drowsy? If not fully alert, to what extent can the patient be roused? A more scientific assessment of the patient’s level of consciousness can be done by means of the Glasgow Coma Scale. The Glasgow Coma Scale provides an overview of the patient’s level of responsiveness. Table 27.3  The Glasgow Coma Scale Criterion

Score

Eye opening Spontaneous To speech To pain No response

4 3 2 1

Motor response Complies with request (obeys command) Localises pain (eg pushing away examiner’s hand)

6 5 ➙

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Criterion

Score

Withdraws from painful stimulus Abnormal flexion (assumes a decorticate position) Extension (assumes decerebrate posture) No response

4 3 2 1

Verbal response Oriented (able to converse) Confused conversation Inappropriate words used Incomprehensible sounds or grunts No response

5 4 3 2 1

Total

/15

Source: Teasdale & Jennett (1974)

The patient is assessed as follows: • Observe the patient’s spontaneous behaviour and note spontaneous eye opening, movement and speech. If the patient is opening his or her eyes spontaneously and looking about normally, a score of 4 can be given under ‘eye opening’. • If the patient is conversing, assess whether the conversation is normal or confused, and score accordingly. • If the patient is awake and moving spontaneously, the nurse should ask the patient to do something simple, like lifting an arm or squeezing the examiner’s hand, and score accordingly. • If the patient is lying with eyes closed and does not open them spontaneously or talk, the nurse should call the patient by name and evaluate the response. If the patient responds to speech, asking the patient to carry out a simple action can assess motor response. • If the patient does not respond to his or her name being called, an appropriate painful stimulus is applied and the response, if any, is evaluated. The stimulus used should be sufficiently unpleasant to be noticed by the patient, but it should not constitute assault. • The resulting Glasgow Coma Score is given as a total out of 15. A score of 15/15 indicates that the patient is fully conscious and alert, whereas a score of 3/15 indicates a complete lack of response and is a grave prognostic sign. At 8/15 and above the patient is conscious, whereas at 7/15 or less the patient is not conscious. NB! Some neurosurgical units use an adapted Glasgow Coma Score. The version given above is the standard version.

Common clinical problems A visually impaired patient A patient who is unable to see well may have difficulty negotiating unfamiliar surroundings. Visual impairment poses a potential medico-legal hazard because there 590

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is a danger that the patient may slip and fall, or bump into objects and get hurt in the process. When caring for a patient with a visual impairment, it is important to ensure that the environment remains constant. If possible, the patient should not be moved from room to room, or from bed to bed, as this becomes confusing for the patient. • Constantly reassure the patient and explain activities and procedures to him or her. • Be sensitive to the patient’s feelings: avoid over-attentiveness, allow independence and do not treat the patient like a child. The nurse should facilitate normal adultto-adult communication with the patient. • Nurses should always introduce themselves and any others, and give the patient a warning of their approach to avoid startling the patient. A light touch on the hand, arm or shoulder may help the patient to realise that someone is nearby. • Always maintain eye contact with the patient: if the patient is partially sighted, he or she will notice that the nurse is attentive. Maintaining eye contact also ensures that the nurse is facing the patient and can therefore be heard by the patient. The nurse will also be able to see the patient’s facial expression, which helps to gauge reactions and responses. • It is important to orientate the visually impaired patient to the environment, including doors, passages and windows. The environment should be as obstacle free as possible. Furniture should not be moved around and should be kept in the same position in the room as far as possible. Doors should be either open or shut, and not half-open. • Avoid moving small items on lockers and other surfaces without the patient’s knowledge. If such items are moved, make sure that the patient knows where they have been placed. • Ensure that the patient knows where the various items of food are on the food tray. • When in doubt, ask the patient whether he or she would like assistance or not. • Assisting a visually impaired patient and walking with him or her is often necessary to avoid problems. • The nurse should, however, assess the patient’s level of independence and act accordingly.

A patient with a hearing impairment A patient with a hearing impairment often has great difficulty in understanding the activities around him or her if the environment is strange. These patients often appear to be slow and as a result are often thought of as being backward or confused. Identification of the patient with a hearing impairment is very important as it enables the nurse to establish an effective system of communication with the patient. • To facilitate lip reading, which many such patients do to an increasing extent as their hearing deteriorates, the nurse should always make sure that the patient is able to see his or her face. • The lips and mouth should not be covered, unless this is unavoidable. Avoid standing so that the light shines from behind the nurse: the lips and face are not easily discernible. • The nurse should not exaggerate facial movements, and should avoid chewing while talking to the patient.

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• The nurse should speak slowly, pronouncing each word clearly, from directly in front of the patient. Interfering sounds, such as music or other people talking in the vicinity, should be avoided. • A gentle touch can be used to warn the patient of the nurse’s approach, or the nurse can ensure that his or her approach is clearly visible to the patient. • Never shout at the patient; talk normally. It may be helpful to drop the tone of the voice as a lower pitch is often more audible than the normal pitch. The nurse should always bear in mind that deafness is not necessarily equated with mental retardation. • Difficult words may, however, need to be written down to achieve clarity of communication. • If the patient uses a hearing aid, make sure that it is working and that the patient uses it. • If available, someone who is familiar with sign language can be used as an interpreter to improve communication, provided the patient understands sign language. • Check the batteries of any hearing aids. • Where possible and necessary, provide paper and pencil so that conversations can be conducted in writing.

A ‘confused’ or delirious patient A ‘confused’ patient is difficult to nurse. Such patients are restless – they may wander about, frequently pulling out lines and tubes, and are often loud and aggressive. The temptation is to leave such patients in a side room and to avoid them as far as possible. Confusion or delirium is, however, an important clinical problem, and one that nurses should never ignore. • Restlessness and confusion is often the first indication that the patient’s condition is deteriorating, and this is particularly true of the elderly. • Delirium in a patient who was previously alert and oriented should always be investigated. Where a specific cause for the delirium can be identified, this should be rectified.

Common causes of delirium • Hypoxia • Electrolyte imbalance • Dehydration – this is common in elderly patients, who invariably do not take sufficient fluids • Hypo-/hypertension • Infection and sepsis • Sensory overload and a strange environment • Renal failure and liver failure – build-up of metabolic waste products, which are toxic to the central nervous system and which give rise to delirium • Alcohol withdrawal – this is a common problem and may occur even in patients who are moderate but regular social drinkers • The effects of drugs • Chronic progressive diseases of the central nervous system, such as Alzheimer’s disease.

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• Restraint invariably makes a confused patient worse and distresses the patient. A restraint is a device that is used to limit the physical activity of the patient or of part of the body. Restraints should be avoided as far as possible and used only as a last resort. It is preferable to allocate a staff member to remain with the delirious patient. This has the advantage of placing the patient under constant supervision because even restrained patients can pull out tubes and climb out of bed. If restraint is necessary, the nurse should ensure that a doctor prescribes this and medico-legal guidelines for restraint are complied with.

Use of restraint • Generally speaking, a doctor should prescribe restraint. In circumstances where a doctor is not available and there is the possibility that the patient may pull out essential tubing or other items of equipment, or the patient’s agitation is such that he or she may fall out of bed if not restrained or is a danger to him- or herself and others, the nurse may apply restraint and ensure that the doctor is made aware of the situation at the earliest opportunity. • Alternatively, especially in units where restraint is frequently needed, such as neurosurgical units, the doctor may approve a general protocol for restraint. • Always apply the minimum of restraint needed to ensure the safety of the patient and to limit movement to the desired extent. • Restraints should be applied securely but not so tightly that they cut off circulation or put pressure on the skin and underlying tissues. Under certain circumstances, restraint may be construed as assault, particularly if it is excessive or if the patient sustains an injury as a result of it. • Bony prominences should be padded to avoid friction from restraining devices. • Limb restraints should always be tied with a knot that will not tighten when pulled. • Restraints should be released at two- to four-hourly intervals to allow for free movement or passive exercises and for purposes of hygiene. While the restraint is removed, the nurse should examine the limb closely for any sign of redness, chafing or broken skin. • Restrained patients should be checked on at regular intervals to ensure that the restraints are still in place and to check on tubing, IV lines and dressings. If there is any sign of cyanosis or swelling on the restrained limb, the restraint should be loosened immediately. • The continued need for restraint should be reassessed on a daily basis. • Always ensure that restraints can easily be removed in the case of an emergency.

Table 27.4  Types of restraint Wrist restraints • Arm movement is restricted, but some ‘play’ should still be allowed • It should not be possible to pull restraints excessively tight so as to cut off circulation to the hand • Avoid friction to the skin of the wrist • Bracelets should be padded for comfort

Figure 27.1  Wrist restraints

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• Restraints may be made from crepe bandages and cotton wool, but ready-made shackles are available Gloves or mittens • Fingers are placed around a cotton wool roll to keep them in a functional position • The hand is securely wrapped so that the fingers cannot work loose • Gloves or mittens may be combined with wrist restraints if necessary

Figure 27.2  Gloves or mittens

Finger restraint • The middle finger is secured with plaster, and the strapped finger is then secured to the bed with tapes • This form of restraint combines a high degree of effectiveness with a minimum of coercion

Figure 27.3  Finger restraint Restraining sheets • These should be applied firmly, but not excessively so • There must be adequate access to drips, drains and catheters

Figure 27.4  A restraining sheet Restraining net A cot bed is essential as the patient may become entangled in lines and bedclothes if very restless

Figure 27.5  A restraining net • In the case of patients who are very restless and agitated, it may be advisable to discuss some form of sedation with the patient’s doctor, particularly if the patient is not sleeping during his or her delirium.

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• Used judiciously, and provided that there is no contraindication, sedation may facilitate effective nursing care and promote rest in the delirious patient. Adequate rest and sleep may, in turn, alleviate confusion and delirium. • The patient’s environment should be as stable as possible. Constant changes and upheavals upset the confused patient, making the problem worse. If possible, personal and familiar objects should be placed in the patient’s environment. • The nurse should constantly reinforce reality with regard to persons, time and place when dealing with the patient. • The nurse should always identify him- or herself to the patient with each new interaction. The patient should always be addressed by name. • The nurse should always show interest and sensitivity towards the patient. He or she should always preserve the patient’s dignity and self-respect, and never tease a confused patient. The nurse should not go along with or reinforce hallucinations or delusions. • The nurse’s behaviour towards the confused patient should always be consistent, and the nurse should alleviate fear and anxiety by constantly reassuring the patient. Never abuse a confused patient, or put such a patient in an isolated room: something potentially serious may happen, or the patient may injure him- or herself without the nurse being aware. • Boredom and sensory deprivation should be avoided. Music and television may help the patient to concentrate and to focus on what is happening around him or her. The nurse should talk to the patient. Conversation may help to improve the patient’s orientation to reality. Escorted walks and outings may also provide interest and help the patient to focus on reality. • The opposite situation of sensory overload should also be avoided. • Nursing activities should be spaced and done one at a time. • A confused patient should never be rushed or hustled, as this distresses the patient and may exacerbate the confusion. It is important to maintain a calm and restful environment as far as possible. • As far as is possible, a proper distinction between night and day should be made. Lights should be dimmed at night, and nursing activities should be carried out as quietly as possible. Wherever possible, the patient should be encouraged to be awake and active during the day. Many confused patients sleep during the day, and are restless and wakeful during the night. The nurse should try to promote a normal sleep/wake pattern. • The nurse should always be aware of possible medico-legal hazards when caring for a confused or delirious patient. Cot sides should be used, especially at night, when confusion is often worse. The patient’s activities should be supervised and the patient should be assisted as needed.

An unconscious patient Unconsciousness is a state of altered awareness in which the ability of the brain to receive sensory impressions and to respond to the environment is impaired. • A state of unconsciousness may be transitory, as in syncope, or it may be prolonged, as in a coma due to a brain injury.

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• The depth or degree of unconsciousness may vary, from a state of stupor from which the patient may be aroused, to a state of deep coma from which the patient is totally unrousable and unresponsive. • Broadly speaking, anything that impairs the functioning of the brain may result in unconsciousness. • Induced coma, the purpose of which is to rest the brain, utilises powerful sedation to render the patient unconscious. Induced coma is used in instances of cerebral oedema or brain swelling, and the enforced resting of the brain during the period of induced coma facilitates reduction of this swelling. If not reduced, cerebral oedema may be fatal. Table 27.5  Causes of unconsciousness Toxic causes

Agents introduced into the body from the outside may impair the function of the brain: • Drug overdose • Alcohol taken in excess • Industrial poisons (eg lead) • Insecticides (eg organophosphates) • Anaesthetic agents

Metabolic causes

Disruptions in metabolic processes may result in an accumulation of metabolic wastes, or other metabolic imbalances, which may adversely affect the function of the brain: • Hypoglycaemia (low blood sugar) • Hyperglycaemia (high blood sugar) • Uraemia (accumulation of urea) • Hepatic encephalopathy (accumulation of ammonia as a result of liver failure)

Hypoxic causes

A reduction in cerebral blood flow, or any decrease in the amount of oxygen and/or nutrients that reach the brain, will impair brain function: • Cerebro-vascular accident or ‘stroke’ • Circulatory failure/shock • Haemorrhage • Cardiac arrest

Cerebral causes

Pathology within the brain itself may impair the function of the brain: • Brain injury • Intracranial haemorrhage • Intracranial tumours • Epilepsy • Infection of the brain and/or meninges • Chronic/progressive conditions of the brain

Other causes

Various other factors may impair the function of the brain: • Hyper-/hypothermia • Severe infection • Eclampsia • Electrocution

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• Knowing the possible cause of a patient’s unconsciousness may be of great value in the treatment of the patient. When admitting an unconscious patient, or when dealing with an unconscious casualty in a first-aid situation, always try to find out as much as you can about the circumstances and events that resulted in the patient’s unconsciousness. • Try to find out, from relatives, friends or bystanders, whether drugs or alcohol may be involved. Alcohol may often be smelled on the patient’s breath. The nurse should be aware, however, that the breath of a patient in a diabetic coma, or keto-acidosis, might smell similar to alcohol. • Diabetics who become hypoglycaemic may often behave in a similar manner to someone who is drunk. Enquire about any systemic illness. Look on the patient for an identification or MedicAlert bracelet. Other clues, such as bottles of medication, may sometimes be found on the patient’s person, or among his or her belongings. Assessment of an unconscious patient

An initial assessment of the patient’s level of consciousness should be made using the Glasgow Coma Scale. For a full assessment of an unconscious patient, other neurological observations should be made, both initially and on an ongoing basis: • The pupils should be examined for size, equality and reaction to light. Normally the pupils should be equal in size and should react briskly to a light shone into the eyes. • Note whether the patient is moving. Observe any abnormal movements such as spasms or convulsions. The nurse should ascertain whether movement is equal on both sides of the body and whether there is any obvious paralysis. • Restlessness should be noted, particularly if restlessness is increasing or decreasing. Increasing restlessness may be an indication of pain, a full bladder or a lightening of coma. • An assessment of the patient’s general physical condition should be carried out in addition to the assessment of neurological status. A general physical examination will include vital signs and a survey of all other body systems, as well as routine diagnostic tests. These routine diagnostic tests should include urine testing, serum electrolytes, blood glucose levels and full blood count, a chest X-ray and an electrocardiogram. Nursing management of an unconscious patient

When caring for an unconscious patient, nurses must be constantly aware of the fact that this patient is totally incapable of meeting any of his or her physical or psychological needs unaided. The unconscious patient is completely dependent on the nurse to meet these needs.

Conclusion The ability to see, hear, feel, taste and smell, as well as the cognitive functions of the brain, serves to protect the patient in his or her environment. Patients who are compromised in these areas are vulnerable and at risk for injuries. Nurses need to be aware of this risk and the extent thereof. Nursing activities, especially the application of restraints, may also put the patients at risk. 597

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Suggested activities for students Activity 27.1 Working in pairs under supervision of the lecturer, students should conduct a full assessment of sensory and motor function on each other, and record their findings. Following this assessment, students should carry out an assessment of general mental state and level of consciousness on each other. NB! The students must observe medico-legal hazards and the ethical obligations applicable in the examination of a patient.

Activity 27.2 Working in pairs and under the supervision of the lecturer, students should carry out the following activities: 1. One of the partners in the pair is blindfolded and is then taken a short distance, for example to the restroom or to the next-door classroom. The roles are then reversed and the other partner is blindfolded. 2. With one student blindfolded, the other partner feeds the ‘blind’ one some familiar type of food and also gives him or her something to drink. The roles are then reversed. 3. One of the partners places cotton wool in his or her ears, while the other gives him or her instructions about upcoming class activities. The roles are then reversed. When all of the students have completed both activities, a class feedback session is held. It is of particular importance for students to explore the feelings they experienced. For such a debriefing to be effective, it should be held immediately after the exercise is completed.

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chapter

28

Peri-operative nursing care

Learning objectives On completion of this chapter, the student should be able to do the following: • Demonstrate competence in peri-operative nursing care to the patient undergoing surgery. • Demonstrate competence in the nursing management of patients undergoing surgery. • Accurately apply techniques for and interpret peri-operative assessment findings. • Effectively recognise and manage peri-operative complications. • Provide health promotion and health education from admission to discharge.

Key concepts and terminology Informed consent: This is the agreement by an adult patient (or parent or guardian in the case of a minor) to undergo surgery following a thorough explanation and a complete understanding of the nature of surgical procedures, treatment options, benefits and the risks involved. Intra-operative period: This is the period from the time that the patient is transferred to the operating theatre table to when the surgery is completed and the patient is taken to the recovery unit. Peri-operative nursing: This refers to the care of the patient before, during and after surgery. It involves three phases from admission to discharge, which include the preoperative phase, the intra-operative phase and the post-operative phase specific to the surgical intervention. Pre-operative period: Pre-operative nursing commences when the decision is made for a patient to undergo surgery and requires the application of the nursing process from admission to handover of the patient to the operating theatre personnel in the receiving area. Post-operative period: This period commences when the patient is transferred from the recovery room to the ward or the intensive-care unit until discharge.

Prerequisite knowledge The nurse should have knowledge of the following: • The scientific approach to nursing

➙

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• Anatomy and physiology • Biochemistry and biophysics applied to nursing • Application of universal precautions • The principles of scientific record keeping • Regulations relating to nursing practice • A basic understanding of the professional, ethical and legal framework of nursing in South Africa • Policies and procedures required by the healthcare facility and healthcare governance.

Medico-legal considerations • Nurses will be guilty of malpractice (omission) as a result of failure to assess a patient thoroughly, leading to problems being overlooked. This could result in inadequate care, or the development of complications. • The scope of practice of the registered nurse authorises the nurse: –– to participate in the preparation for and assistance with operative and diagnostic procedures –– to meet the full spectrum of bio-psychosocial needs as relevant in caring for the surgical patient –– to prepare for and assist with peri-operative, diagnostic and therapeutic acts for the patient –– to keep accurate and complete records of the patient. • The nurse is responsible for the safety of the patient during the preparation for and delivery of care. This includes responsibility for environmental hygiene such as instrument cleaning and sterilising, and the disposal of waste.

Ethical considerations • Informed consent is a patient right, and therefore written consent is required before some invasive diagnostic studies are carried out. Before they sign consent, patients are entitled to a full explanation of the nature and consequences of the proposed surgery and their rights and responsibilities. • It is the duty of the patient’s surgeon to give full information, and the nurse simply verifies that it has been done. Witnessing consent to surgery implies that the nurse witnesses the patient’s signature and the fact that the patient has been informed, and is prepared to answer questions from the patient. • Nurses are obliged to ensure confidentiality of all information relating to the patient obtained during surgery. The exact nature and extent of the patient’s surgical procedure should be kept confidential, and details should not be disclosed to anyone without the patient’s express consent. Naturally, relatives need to be reassured about the patient’s wellbeing and progress, and the nurse should do this but without discussing details. If necessary, relatives can be referred to the surgeon for discussion of their questions. ➙

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• In accordance with the South African Patients’ Rights Charter, patients must be allowed to exercise their right to a second opinion, to refuse treatment and to participate in their own care and decision making. Patients should be involved in the plan of their own care based on their ability to participate in and make decisions regarding this. • The nurse must treat all patients with dignity and respect at all times, including when they are under anaesthesia. Patients should never be exposed unnecessarily, and should never be spoken about in crude or disrespectful terms. Some patients do not lose their sense of hearing under anaesthesia, especially if a light anaesthetic is used, and are therefore able to recall what was said about them when they wake up.

Nursing implications General problems of negligence in clinical practice that can lead to incidents or accidents involving the care of surgical patients include the following: • Failure to test urine and report glucose levels pre-operatively • Failure to check that a valid and legal consent document has been signed • Failure to check previous allergic responses of the patient • Failure to identify or check identity tags, allergy bands, the physical condition of the patient and the operation site • Failure to note and report anaesthetic and post-operative complications • Failure to monitor vital signs and other parameters pre- and post-operatively • Failure to adhere to established guidelines or standards of practice that guide patient care • Failure to keep concise, accurate and properly signed patient care records.

Introduction Surgery is an important treatment option in the management of many conditions, and the quality of the care given to patients may directly influence their progress and recovery. Surgery is a total experience for the patient and involves psychosocial, spiritual and physical dimensions. Appropriate patient education is needed, and certain legal and ethical prescriptions must be taken into account and fulfilled. Surgical procedures vary from hospital to hospital; however, the basic principles remain the same. The purpose of peri-operative nursing is to restore or maintain the health and welfare of the patient before, during and after surgical intervention. In this chapter, the student will be introduced to peri-operative nursing, the surgical team and the roles of the various categories of staff in the operating theatre, the equipment and the principles underlying care. Recovery from surgery involves the application of post-operative care, encouragement and education. Nurses are encouraged to develop competence in the assessment and management of actual and potential risk factors preoperatively, with a view to facilitating recovery post-operatively.

Surgery Surgery or surgical operation is done to correct deformities and defects, repair injuries, diagnose and cure disease processes, and relieve suffering. The patient’s decision to 601

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undergo surgery is based on the information provided by the surgeon with regard to the nature of the surgical procedure, all the treatment options, and the risks and benefits involved.

Indications for surgery The indications for surgery are the following: • Conditions for which medical management is not appropriate or has failed, such as peptic ulcers or tumours, may need surgery. • Certain conditions are, by definition, surgical, and can only be cured or corrected by surgery. These include the repair of congenital defects, the repair of injuries, the removal of obstruction of the natural flow of blood or gastric contents, and the removal of damaged organs/tissues. • Surgery may be undertaken in order to establish or confirm a diagnosis, for example the removal and examination of suspicious breast lumps (biopsy). • Surgery may be undertaken to determine the extent of pathology, and may include various exploratory procedures. Types of surgery There is more than one way to classify surgery, as shown in Table 28.1. Table 28.1  Classification of surgery 1. According to the extent of the procedure, the possible effects on the body and the known risks of the procedure

• Minor surgery: Causes relatively little disruption of function and has few risks • Major surgery: May cause considerable disruption of function, and the risks involved are greater. Surgery that involves the opening of any body cavity is always classified as a major procedure

2. According to the objective and character of the procedure

• Ablative surgery: The total removal of a diseased organ or structure, for example the removal of cancerous organs and tissues • Constructive surgery: The correction of abnormal anatomy to improve function, for example the repair of congenital defects • Cosmetic surgery: The alteration of parts of the body to improve appearance as perceived by the patient, for example a facelift or skin graft • Curative surgery: Performed in order to arrest a pathological process • Palliative or non-curative surgery: Performed to alleviate symptoms and improve the quality of life of the patient • Diagnostic surgery: Carried out in order to establish a diagnosis, for example a biopsy • Exploratory surgery: Carried out to assess the extent of a lesion or pathology • Prophylactic surgery: The removal of tissue and/or organs that are not vital and are likely to develop into a ➙ disease, for example polyps

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• Reconstructive surgery: Performed to reconstruct a defect or in response to trauma in an attempt to improve function, to obtain a more desirable cosmetic effect or to restore normal appearance, for example the patient with burn wounds. Reconstructive surgery involves the repair of parts of the body to improve function, for example plastic surgery excluding cosmetic surgery 3. According to the urgency of the procedure

• Elective surgery: Can be planned and scheduled at the convenience of both the patient and the surgeon. This type of surgery is also known as ‘cold’ surgery. Elective surgery involves conditions where the patient’s pathology can be controlled until conditions are favourable for surgery, or where the patient is neither endangered nor seriously inconvenienced if surgery is postponed • Emergency surgery: Urgent surgery that must be performed as soon as possible, often immediately. This type of surgery is the so-called ‘hot’ surgery. Emergency surgery is necessary if the patient’s life is in danger, or if the patient’s condition cannot be stabilised and progression of the condition would lead to death or severe disability

Clinical alert! Every surgical procedure involves some risk to the patient.

The effects of surgery on the patient Surgery involves the deliberate invasion of the body and the handling of its tissues. Surgery is, therefore, an insult and an assault on the body. All forms of surgery, with the exception of very minor procedures, have a range of physiological and psychological effects that must be taken into account when planning the care of the surgical patient. Stress response

Surgery is an insult to the body, and as such will cause the activation of the body’s stress responses, namely the following: • Activation of the sympathetic nervous system and the ‘fight or flight’ mechanism • Release of catecholamines (adrenaline and noradrenaline) to augment the effects of the sympathetic nervous system • Release of corticosteroids from the adrenal cortex that alters the body’s metabolism to enable the body to cope with the stress of surgery. Surgery is also stressful psychologically as it involves fear of the unknown, fear of death or mutilation, as well as practical fears regarding the effect of surgery on the patient’s body and lifestyle. This psychological stress further amplifies the stress response.

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Nursing assessment and findings In stressful situations the following occur: • Raised blood pressure • Increased pulse and respiration rate • Nervous reactions and/or anxious appearance • Shivering and/or trembling • Nervous spasms • Pallor due to activation of the sympathetic nervous system. Respiratory system

• The agents used in general anaesthesia, such as Enflurane, Isoflurane, Thiopentone and the opioid anaesthetic agents, depress the respiratory centres in the brainstem, causing respiratory depression and poor alveolar ventilation. • The use of muscle relaxants, such as suxamethonium or pancuronium bromide during surgery may result in weakness of the respiratory muscles in the immediate post-operative phase. This further contributes to poor alveolar ventilation because of poor lung expansion. • Inhalation anaesthetic agents, such as Isoflurane, as well as the endotracheal tubes used to administer these agents, cause irritation of the bronchial mucosa. This leads to an increase in bronchial secretions post-operatively. These secretions need to be coughed up and expectorated, as their retention will impair gas exchange and they are likely to become infected. • Pain and restriction of movement after surgery tend to inhibit coughing, leading to retention of secretions, impaired gas exchange and possible lung infection.

Nursing assessment • Monitor respiration rate, depth, rhythm, chest movements and breath sounds. • Note colour of skin and mucous membranes. • Note any cough and/or secretions for amount, consistency and colour. • Monitor pain during breathing. Cardiovascular system

• Surgery inevitably involves the loss of body fluid in the form of blood and plasma. This may cause hypotension and inadequate circulation post-operatively if not corrected at the time of surgery or immediately thereafter. • The anaesthetic agent, for example halogenated hydrocarbons like Halothane or Fluothane, may depress the vaso-motor control centres in the brainstem that are responsible for maintaining a stable blood pressure. The result is hypotension. • Some anaesthetic agents, particularly the halogenated hydrocarbons, depress the myocardium, causing a drop in cardiac output and blood pressure. Myocardial depression also increases the risk of cardiac arrhythmias in the post-operative phase.

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• After surgery the blood becomes more coagulable. This is a protective mechanism and is part of the healing process, but it makes the patient more susceptible to thrombus formation. The risk of deep vein thrombosis and pulmonary embolism is therefore increased after surgery.

Nursing assessment • Monitor blood pressure, whether increased or decreased. • Monitor pulse rate, volume and rhythm. • Note any loss of blood or any other type of body fluid for type and amount. • Monitor the level of consciousness. • Monitor any pain in the leg or chest. Gastrointestinal system

• Some anaesthetic agents, notably ether, irritate the gastric mucosa, causing nausea and vomiting in the immediate post-operative phase. Opiate analgesics when given as part of the pre-medication, or as part of the anaesthetic itself, may cause vomiting through stimulation of the vomiting centre in the brainstem. • The bowel becomes sluggish, and peristalsis is reduced. This is a result of limited oral intake, anaesthesia or, in the case of abdominal surgery, the physical handling of the intestines during the procedure.

Nursing assessment • Note any nausea and/or vomiting. • Monitor bowel movements and the passage of flatus. Urinary system

A reduction in urinary output may occur due to fluid retention and reduced fluid intake. In some instances, urine is retained due to sphincter spasm following surgery. The fluid retention occurs as a compensatory mechanism to make up for losses of body fluid incurred during surgery. The effect of the anaesthetic agents causes a degree of muscle relaxation and may cause a decrease in bladder tone, leading to retention of urine and difficulty in micturition.

Nursing assessment • Monitor intake and output. • Assess skin turgor and dryness, and the presence or absence of perspiration. • Note any dryness of the mouth. • Monitor micturition – that is, the amount of urine passed and any difficulty in passing it. • Do urinalysis and note any abnormalities that can be detected, for example specific gravity. • Note any oedema.

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Metabolism

As part of the healing process, the metabolic rate increases. This increase in the metabolic rate brings about an increase in the patient’s nutritional requirements, and causes a slight increase in body temperature of 1 or 2°C.

Clinical alert! A marked increase in temperature post-operatively is not normal and usually indicates infection.

If the patient’s nutritional requirements are not met, body fat and tissue protein will be broken down to meet the need, which will retard the healing process. Such a breakdown of tissue protein is evidenced by an increase in the amounts of urea excreted in the patient’s urine.

Nursing assessment • Note appetite when the patient begins food intake. • Do urinalysis and note any abnormalities that can be detected, for example proteinuria. • Monitor body temperature. Musculo-skeletal system

• During the operation the patient is immobile and may, in addition, have been placed in an awkward position on the theatre table to facilitate surgery. As a result, generalised aches and pains are common following surgery. • Muscular aches and pains are also caused by the effects of muscle relaxants given as part of the anaesthetic. Scoline, a very commonly used muscle relaxant in anaesthesia, causes muscle twitching and jerking before producing relaxation. These twitches and jerks are also responsible for the aches and pains experienced by the patient. • A sore throat may be caused by the stretching of the glottis and vocal cords during passage of the endotracheal tube at induction of anaesthesia.

Nursing assessment • Assess the patient for aches, pains and general discomfort. • Note the presence of musculo-skeletal co-morbidities such as arthritis. • Assess the patient for a sore throat, swelling around the neck or loss of voice. Nervous system

• The agents used in general anaesthesia, whether inhalation agents like halothane or intravenous ones such as thiopentone, act on the brain and may interfere with mental function, causing confusion and disorientation. These effects are more marked in elderly patients. 606

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• The anaesthetic may also affect muscular co-ordination. • Pain and discomfort may interfere with rest and sleep, both of which are essential to the healing process.

Nursing assessment • Monitor the level of consciousness. • Note orientation and mental function. • Monitor pain and discomfort. Defence mechanisms

• During surgery the body’s first line of defence against invasion by microbes, which is the skin, is breached. Bacteria may gain access to the tissues through a surgical wound, causing infection. • The hormones secreted as part of the stress response (eg adrenaline, noradrenaline and corticosteroids) reduce the body’s resistance, making the patient more vulnerable to infection after surgery. • Histamine is secreted in the event of anaphylactic reactions.

Nursing assessment • Observe any evidence of infection – that is, pain, pyrexia, redness or swelling around the operation site. • Note any allergies. Body image

During surgery, the patient’s body is altered to a greater or lesser extent. The function of the body may also be affected. Surgery also means that the patient’s body has a wound, which could become a disfiguring scar. The appearance of the body, as well as altered function, may lead to considerable psychological distress for the patient. Naturally this varies with the extent of the surgery and the patient’s understanding of the procedure, the reasons for the procedure, as well as the general importance that the patient attaches to appearance and body image. The greater the difference in appearance following surgery, the greater the distress, for example the potential effect of a mastectomy on a woman’s body image.

Nursing assessment • Observe the patient for any signs of depression, anxiety and/or irritability. • Note any distress or negativity regarding the surgery or body image. • Note verbalisation of feelings.

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Lifestyle

Surgery may alter the function of an organ, making a change in the patient’s lifestyle necessary; either to prevent a recurrence of the condition which necessitated the surgery, or to enable the patient to function optimally following surgery (eg following a colostomy). Specific alterations in lifestyle depend on the type of surgery. Psychosocial, cultural and spiritual aspects

Psychological discomfort is important as it directly influences homeostasis. The family and significant others must also be involved. Patients are often concerned about their families, their jobs, being a burden to the family or the threat of incapacity. These must all be considered. Spiritual and cultural beliefs play a major role in alleviating fears and emotional distress. Careful noting of cultural and psychosocial issues in the history taking during assessment is important.

Nursing assessment • Observe the patient for any signs of depression, anxiety and/or irritability. • Note any distress or negativity regarding surgery or body image. • Observe verbalisation of feelings.

Factors that affect the patient’s ability to cope with surgery Surgery involves an inherent risk to the patient, no matter how minor the procedure. Surgical risk increases with the length and complexity of the procedure. Certain patient factors may further increase the risk involved, which are described below. Age

The very young and the very old have a significantly increased risk when undergoing surgery. • The circulatory and renal systems of infants are immature, making it more difficult for the infant to cope with the stress of surgery. • The elderly have diminished cardiac, circulatory, respiratory and nutritional reserves, which increases the likelihood of anaesthetic and post-operative problems. In addition, the elderly are more likely to suffer from chronic underlying diseases, which may be unrelated to the main surgical problem but which will, nevertheless, complicate their recovery. Elderly patients are more sensitive to drugs and are thus more likely to present with adverse effects. General health

• A patient in good health is better able to withstand the stress of surgery than one who is in poor health. Many of the factors relating to general health may, if severe, result in the postponement of elective or non-emergency surgery until the problem can be eliminated or controlled. • Pre-existing pulmonary conditions increase the risk of post-operative lung complications. Smokers are also at greater risk for the development of post-operative pulmonary complications.

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• Cardiac conditions may impair the ability of the body to maintain an adequate circulation and blood pressure during surgery and anaesthesia. A diseased heart is unable to compensate for blood loss and the effects of anaesthetic drugs. It should also be borne in mind that many anaesthetic agents actually depress the myocardium, causing hypotension and an increased risk of arrhythmias. This depressant effect will be exacerbated in the face of pre-existing cardiac and/or circulatory disease. • Diabetes mellitus is frequently associated with cardiovascular disease. In addition, the diabetic patient is more susceptible to infection. Poorly controlled diabetics may be slow to heal following surgery. • Poor nutrition as well as obesity may retard wound healing. Under-nutrition, in particular, lowers the patient’s resistance, increasing the risk of infection. Obese patients are more likely to suffer cardiac and respiratory complications during and after surgery, and their wounds may be slow to heal, which increases the risk of infection. • Septic lesions anywhere on the body increase the risk of wound infection postoperatively. • Deficiency of the immune system lowers the patient’s resistance and increases the risk of infection post-operatively, for example patients who are immunocompromised, who have recently undergone radiation, or who are taking steroids or immunosuppressive drugs. Mental state

Patients who are very fearful and anxious prior to surgery are at risk for the following physiological reasons: • The stress of surgery causes the release of substances, such as catecholamines and corticosteroids, which increase cardiovascular instability and depress the immune system, increasing the risk of anaesthetic and post-operative complications. • Stress causes the release of adrenaline and noradrenaline. These substances sensitise the myocardium, potentiating the effects of anaesthetic agents on the heart. The chances of the patient developing profound hypotension or an arrhythmia under anaesthesia are therefore increased. Medications

Certain medications taken by the patient may have a significant effect on the result of surgery: • Anticoagulants (eg warfarin) may cause intra- or post-operative bleeding. • Tranquillisers (eg diazepam) increase the patient’s tolerance of those drugs that depress the central nervous system. Such a patient may require larger doses of anaesthetic agents, which in turn will increase the risk of anaesthetic complications. • Steroids (eg cortisone) depress the immune system. • Beta adrenergic blocking agents (eg propanolol (Inderal, InnoPran)) and antihypertensive agents (eg Aldomet) may depress cardiovascular reflexes, decreasing the patient’s ability to maintain normal blood pressure and adequate circulation during and after surgery.

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The extent of the procedure

• • • •

The more extensive the procedure, the greater the risk. The longer the procedure, the greater the risk. The more complex the anaesthetic, the greater the risk. Risk is always increased if a major body cavity is to be opened.

Nursing assessment of the special needs of the patient undergoing surgery A full assessment of the patient is necessary pre-operatively. Assessment is carried out from both a medical and a nursing perspective. The patient is examined by the surgeon, by the anaesthetist, and also by the nurse. The purpose of such an assessment is to identify factors that might impact on the course and outcome of surgery: • The nurse should get to know the patient and his or her family. As part of the admission process, the patient’s name, age, religion, address and occupation will be known, but it is worth spending extra time to get to know a little more about the patient, his or her family and circumstances. Getting to know the patient establishes a rapport with the patient and family, and makes support and education of the patient and family more real and personalised. • The nurse must also assess the learning needs of the patient, including the information the patient was given by his or her doctor about the proposed operation, and any preconceived ideas or misconceptions about the surgery. Tactful questioning may also reveal whether the patient has any deep-seated intuitive fears of anaesthesia and surgery. The nurse must also assess the patient’s level of understanding, as information must be geared to the patient’s ability to absorb it. • A full history is taken from the patient. It is particularly important to ascertain the existence of chronic disease, especially chronic lung disease, cardiovascular disease and diabetes mellitus, as these conditions may lead to complications post-surgery. • The nurse must also find out about any allergies and medications being taken by the patient. The nurse should ask specifically about anticoagulants, steroids, betaadrenergic blocking agents, anti-hypertensive medications and sedatives, as these drugs may influence the patient’s response to anaesthetic agents. It is also important to explore aspects such as smoking, diet and alcohol usage. • A full physical assessment of the patient is carried out, noting the condition of the skin and any deformities and lesions present, including routine baseline vital signs and urinalysis. The nurse must also assess the patient’s ability to carry out normal activities of daily living, as this will impact on nursing care in the post-operative phase. The nurse should also be aware of any disabilities in order to be able to care effectively for the patient during his or her stay in the surgical unit. • Routine diagnostic tests include a chest X-ray, electrocardiogram, Hb, full blood count and blood chemistry. More specific diagnostic tests may be carried out, depending on the operation. The status of any known medical problems is investigated by carrying out the appropriate diagnostic tests. • During the 24 hours immediately prior to the surgery, the anaesthetist examines the patient in order to determine the type of anaesthetic that will be given, and also to ascertain whether any special procedures or techniques will be needed. The 610

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•

•

• •

anaesthetist will prescribe pre-medication, which will be given about one hour before the patient goes to theatre, or when instructions are phoned through from theatre. The anaesthetist may also prescribe sedation to be given the night before surgery to facilitate a good night’s rest for the patient. The nurse should make available the results of all diagnostic and laboratory tests carried out on the patient. The surgeon visits the patient to answer any questions and give reassurance, and to check for any last-minute problems. The nurse should ensure that all results of diagnostic and laboratory tests are available. The patient may be visited by the theatre nurse, who will introduce him- or herself to the patient, answer any questions and assess the patient for any problems which he or she will have to take into account while the patient is actually in theatre (eg prostheses and disabilities). The physiotherapist may visit the patient to make sure that the patient is conversant with any necessary breathing, coughing and leg exercises. The nurse should make a thorough assessment of the patient in the 24 hours just before the surgery, do any skin and/or bowel preparation if necessary, and report any problems to the surgeon.

Nursing management of the patient undergoing surgery The surgical experience embraces three distinct phases:

Stages in the surgical experience 1. Pre-operative phase: This is the period of time prior to the operation during which the patient is prepared physically and psychologically for surgery. 2. Intra-operative phase: This is the period of time when the patient is in theatre and during which the surgical procedure is carried out. This phase includes the time spent inducing anaesthesia, the time under anaesthesia and the time spent in the recovery room. 3. Post-operative phase: This is the period of early convalescence that is spent in the surgical ward. This phase may also include the patient’s convalescence at home prior to the resumption of work and other activities.

Pre-operative nursing Pre-operative nursing embraces the care of the patient prior to surgery from the time of admission to the surgical unit up until the time that the patient goes to theatre for the operation. Aims of pre-operative care

The aims of pre-operative care are threefold: • To make surgery as safe and as comfortable as possible for the patient • To allay fears and anxiety • To prevent post-operative complications by ensuring that the patient is in a state of optimum physical health.

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Psychological preparation

Psychological preparation for surgery is of the utmost importance as the fearful patient is a surgical risk. Good psychological preparation makes the experience more positive for the patient, and facilitates normal healing and recovery. Adequate psychological preparation can arguably be regarded as potentially life-saving. Sources of anxiety To prepare the patient adequately for surgery, it is important for the nurse to be aware of the possible reasons for anxiety, as these will often not be overtly stated. Reasons for anxiety include the following: • Fear of the unknown. This includes fear of death, fear of unconsciousness, fear of pain and fear of helplessness. • Fear of the outcome and worries about the consequences of surgery. This includes fear of finding cancer, fear of loss of function and mutilation, worries about being off work, finances, and the effects of surgery on family and social life. Manifestations of anxiety Sometimes a patient will tell a nurse directly that he or she is worried and why. Often the nurse has to infer anxiety from the patient’s non-verbal communication and from his or her behaviour, which may include the following: • The patient may be silent and withdrawn. • The anxious patient may appear helpless, unable to cope and depressed. • Some patients regress, becoming dependent, childlike and overly demanding. • Other individuals become ‘difficult’, manifesting with aggressive, belligerent behaviour and being thoroughly unpleasant. The family of such a patient will often tell the nurse that such behaviour is ‘not like him or her at all’, which should alert the nurse to the fact that this difficult behaviour is due to anxiety. • Some patients may become tearful and agitated, and have difficulty sleeping.

Dealing with anxiety • Ascertain how much the patient has been told by the surgeon. Arrange for an explanation by the surgeon if this has not been done, or if the patient requests such a visit or has questions beyond the nurse’s scope of practice. • Ask the anaesthetist to explain the anaesthetic procedure and answer questions during his or her routine visit. • Reinforce the surgeon’s explanation. • Listen to and answer the patient’s questions honestly. • Give the patient an explanation of the procedure and what to expect – that is, preand post-operative tests and procedures, the role of other health team members, being nil-by-mouth, mobilisation, dependence, pain and pain control. • Remain accessible and approachable. Allay anxiety, and reassure and support the patient. • Arrange spiritual support and assistance if desired. • Arrange for the physiotherapist to visit the patient. The physiotherapist will teach the patient about various procedures that will be carried out post-operatively, such as breathing, coughing and leg exercises. ➙

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• In many surgical units, the theatre nurse will visit the patient pre-operatively to explain what happens once inside the theatre and what to expect in theatre. • Provide ongoing reassurance and support. Be accessible, and allow the patient to ask any questions regarding the surgery. Modification of surgical risk factors

One of the primary aims of pre-operative care is to make surgery as safe as possible for the patient, as well as to prevent post-operative complications. The way to achieve these goals is by reducing or eliminating the known surgical risk factors in the patient. • If the patient is a smoker, he or she should cut down or, ideally, stop smoking. The patient should be taught deep-breathing and coughing exercises. • Most surgeons are reluctant to operate on patients with active lung infections, unless the operation is an emergency. Lung infection must be treated and cleared up before surgery. • A well-balanced diet containing adequate kilojoules, fats, proteins and vitamins is encouraged in order to ensure that the patient has sufficient nutritional reserves to facilitate normal healing and recovery. If the patient is severely undernourished, surgery may be deferred until the patient’s nutritional status has improved. Likewise, if the patient is obese, surgery may be postponed until the patient has lost weight. • Anaemia, as well as fluid and electrolyte imbalances, should be corrected. • Underlying diseases, such as hypertension and diabetes mellitus, must be brought under control before surgery can be performed. • Any septic lesions must be treated and cleared prior to surgery. • Alcohol intake should be cut down pre-operatively.

Medico-legal aspects Consent is required for all procedures that involve the invasion of body tissues, therefore all surgical procedures require consent, no matter how minor they may be.

Clinical alert! Obtaining consent is the doctor’s responsibility; the nurse confirms the fact that the doctor has discussed the proposed surgery when she asks the patient to sign the consent form. If the doctor has not discussed the procedure with the patient at the time of signing the consent form, the nurse must request him or her to do so before the patient signs the form. In practice, however, it is often not possible for the doctor to come at a moment’s notice. This fact, as well as the time constraints involved, often complicates the issue of consent and particularly that of informed consent.

Preparation of the patient for surgery in the ward After the decision is made by the surgeon that the patient requires a surgical intervention, the ward nursing staff are informed and the operating room is booked. Preparation for surgery is prescribed by the surgeon and the anaesthetist, and includes the following: 613

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• Consent for surgery: This document is a legal requirement. Consent is taken by the surgeon from the patient or the guardian, and is witnessed by a nurse. The nurse witnesses that the patient or guardian has understood the consent, the site of surgery is documented and indicated by the patient, and the patient has signed it in the presence of the nurse.

Medico-legal hazards relating to consent forms • The form has not been properly filled in. • The form does not specify the procedure to be performed. • The person signing is not legally competent to sign a consent form. • The form has been signed by a distant relative where closer relatives are available, or by a person not legally authorised to act as a guardian of a minor, such as the boyfriend of a divorcée who is not the biological father of her child. • The form has been signed after the pre-medication has been given. • The signature is not properly witnessed. • A consent form is being used for more than one procedure. Each surgical procedure must have a separate consent form. • Improper procedures are followed in the case of a medical superintendent or magistrate’s consent. • Only one person has signed for the telephonic consent. • The form is not dated, or is dated after the surgical procedure has been carried out. • The form has been signed under duress, or the patient does not understand what is being signed for. Although it is difficult to prove duress in a court of law, it should be borne in mind whenever a surgeon persuades a patient to sign consent.

• Oral intake: Children under two years of age are allowed breast milk or infant formula up to six hours before surgery. Adults are generally kept nil-by-mouth from 22h00 the night before surgery. However, depending on the type and scheduled time of surgery, they may be allowed a light meal or fluids six hours before surgery. • Skin preparation and clothing: All patients are encouraged to shower using antiseptic soap on the morning of the planned surgery. The hospital policy and the surgeon’s preference must be adhered to. For example, orthopaedic surgeons may require the limb to be painted with surgical disinfectant and wrapped in a sterile surgical towel. If prescribed, shaving of the surgical site should only occur on the day of the surgery, as bacteria may colonise in the microscopic abrasions caused by the razor. The patient is dressed with a surgical gown and cap. Usually disposable underwear is worn; however, the surgeon may authorise differently, depending on the procedure. All babies wear disposable nappies. • Identity bracelet: All patients have to wear an identity bracelet. In some hospitals, the patient wears three (which may be distinguished by the colours white, pink and yellow): one with the patient’s name and number, one with the type of operation to be done and the other one for any allergies such as a latex or implants such as a pacemaker. It is important to check on which wrist or ankle the band should be placed so as to prevent it being removed for the insertion of an intravenous line.

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• Anxiety: Fear of surgery is a normal emotional reaction, and reassurance and empathy by the nurse is expected by the patient and guardians (Fincher, Shaw & Ramelet 2012: 952). Research shows that different cultures experience anxiety differently and it is important for nurses to acquire the knowledge relevant to the patient and adjust their interaction with the patient accordingly (Almutairi, McCarthy & Gardner 2014: 6). Pre-operative preparation of children and their parents between two to three days before admission, with the emphasis on pain education, reduces the long-term risk of psychological complications in children (Fincher et al 2012: 953). • Premedication: This is prescribed by the anaesthetist to be administered at a specific time. The prescription may include an anxiolytic, anti-emetic and the instruction to stop or continue the patient’s routine or chronic medication. Sometimes the theatre nurse phones the ward staff to instruct them to administer the medication at a specific time. • Patient file: The patient’s file should contain the consent for surgery, the perioperative nursing record, the medication prescription sheet, laboratory results, X-ray reports and sufficient patient labels. A pre-operative check sheet should be fixed to the outside of the file and all areas ticked off, or crossed through if not appropriate. • Transporting the patient to the operating theatre: The hospital policy will indicate whether a porter and a theatre nurse fetch the patient, or if the porter and the ward nurse bring the patient to the operating theatre reception area. A detailed handover is required between the ward staff and the theatre nurse, and signatures are placed on the pre-operative checklist.

Common mistakes to avoid The South African Nursing Council can impose sanctions on nurses who are found negligent in their duty to take care, therefore the nurses should do the following: • Always check the pre-operative preparation and medical prescription with a colleague. • Report abnormal test results to the head nurse or the doctor. • Know the ethical and legal requirements for informed consent. • Perform all safety checks diligently, for example allergies such as latex, complications following previous surgery, past history of anaesthetic difficulties, and correct identification of the patient, including identity bands, skin integrity on admission, operation site and planned surgery.

Intra-operative care Surgery takes place in a special department of the healthcare institution or healthcare clinic, usually referred to as the operating theatre or operating room. The name ‘theatre’ arose because early operating areas resembled a theatre, with the patient being surrounded by tiers of seats on which medical students sat to watch the surgical procedure. The aim of nursing in the operating theatre is to restore or maintain the health and welfare of the patient during the actual surgical intervention.

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On arrival in the theatre reception area, the patient, if conscious, is asked his or her name, which is checked against the identity band and the details are recorded in the patient’s file. It is noted when the patient last took food or fluid by mouth. The nurse also checks whether dentures are present or not, and also the type of surgery to be done.

Checking the patient • Although the receiving nurse in the waiting area checks all the documents on handover by the ward staff, the scrub nurse repeats the process. • The theatre nurse greets the patient and introduces him- or herself by rank, name and function. • The patient is asked to verify his or her name, and this is checked against the identity band and the folder/hospital number. • The consent document is checked and the signature or thumb print is acknowledged by the patient if conscious. • The type and site of surgery are confirmed. The theatre nurse checks for allergies, impairment (deafness), dentures and implants, last oral intake and whether premedication was administered to the patient.

Preparation of the operating room • Organisation of surgical list: The theatre secretary collates the surgical list in collaboration with the surgeons, anaesthetists and head nurse. The list is published the day before, and copies are delivered to the other hospital departments such as the wards and the hospital management. The surgical list is a medico-legal document; and it indicates the planned surgical time for each patient; the patient’s title, first name or initials and surname; the gender and age of the patient; and the planned surgical procedure. Depending on the hospital, the ward number or name is also included. Any specialised equipment that has to be ordered specifically for the surgery is added to the surgical procedure to remind the operating theatre team. The surgeon’s and anaesthetist’s names are included for each patient. • Delegation of nursing staff: The head of nursing either completes a delegation book or uses a white board to indicate the names of the staff responsible for a particular surgical list. A registered professional nurse, or an enrolled nurse under the direct supervision of a registered professional nurse, will act as scrub nurse, and will work with two other nurses: one to assist the anaesthetist and the other to take the circulating or floor nurse role. • Setting out surgical equipment: It is the theatre nurse’s responsibility to check that the supplies are present according to the type of operation to be performed, the surgeon’s preferences and that the sterile packs are intact and dry. Before the skin preparation and draping commences, the swabs, instruments, needles and miscellaneous equipment are counted. The scrub nurse checks and counts the instruments against the instrument checklist to make sure that no instrument is missing off the set. The circulating nurse witnesses this. The instruments are arranged on the instrument trolley in order of use.

The swabs are counted audibly and visibly (Joint Commission 2013: 3) in batches of five by the scrub and circulating nurse. Each swab is checked for radio-opaque

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tape. No swab may be used in surgery that does not have a radio-opaque marker; for example, plain gauze as the mark confirms sterility. The circulating nurse writes the swabs up on the swab-monitoring board according to type. During the surgery, any additional equipment added to the sterile field is counted and recorded on the swab board. • Positioning of the patient and applying the diathermy electrode: The patient is positioned by the surgeon with the assistance of the nurses and the anaesthetist. It is important for the scrub nurse to check the application of the diathermy electrode and the padding of the patient to guard against skin and nerve damage due to pressure or electric burns. The diathermy electrode is applied to skin that is not scarred and usually over a muscle, but never over a bony prominence. It is commonly applied to the thigh, but in small children it can be applied to the back. • Disinfecting the patient and applying the towels: Skin disinfectant is selected depending on the site and nature of the surgery and the surgeon’s preference. The circulating nurse is required to show the label of the disinfecting solution to the scrub nurse to verify that it is the correct product before carefully pouring it into the container provided by the scrub nurse. Before disinfecting the skin, the scrub nurse asks the anaesthetist for permission to start. The anaesthetist must be satisfied that the patient is stable. Painting the disinfectant onto the skin occurs in a systematic manner, depending on the surgery. Evidence-based practice recommendations are that the disinfectant should be allowed to dry on the skin before towels or drapes are applied. The count of all the instruments, swabs, needles and other items audibly with the circulating nurse (Joint Commission 2013: 3) is repeated before each subsequent layer of wound suturing, and the surgeon must verbally and audibly acknowledge this. However, if there is a discrepancy then the following takes place: • The surgeon checks the wound for any equipment. • The count is repeated and if a swab is missing, the operating unit nurse manager is informed. • The discarded swabs are taken out of the bucket and laid out on a sheet of paper on the floor. • The waste containers are checked and if the missing swab is not found, the patient is taken for X-rays. If the X-rays do not reveal the swab, the surgeon makes the decision to proceed with closing the wound. • A note is made on the peri-operative patient record that a discrepancy in the swab count occurred. • A nursing statement is written by the scrub and circulating nurses.

After the wound is closed and the dressing applied, the drapes are carefully removed to prevent blood spillage. The diathermy electrode is removed and the site is checked for burns. The patient is checked for skin damage and blood smears, wiped clean and covered with a clean surgical gown and blanket. A nurse remains next to the patient during the reversal of the anaesthetic. Once the anaesthetist is satisfied with the condition of the patient, the patient is disconnected from the monitoring devices and transferred gently onto the bed by the surgical and nursing team. 617

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The patient is then transported to the recovery room, escorted by the scrub nurse and anaesthetist. The anaesthetist maintains the patient’s airway and may elevate the head of the bed. The patient’s intravenous solution is attached to a drip stand, drainage bags are secured to a floor stand, oxygen is supplied via face mask if indicated, and the patient is connected to a baumanometer and pulse oximeter. The scrub nurse then hands over the patient to the recovery nurse. and the following details are verbally and audibly conveyed: • Patient’s title, name and age • Allergies and medical conditions such as hypertension or diabetes • Surgical procedure • Skin closure, dressings, drains and catheters • Medication administered and medication prescribed • Any complications.

Nursing care of the patient in the recovery room The initial function in the immediate post-operative period is to maintain respiration by suctioning the patient. The patient can be positioned on the side until the swallowing reflex returns. The recovery nurse monitors the patient’s vital signs every five minutes until resumption of motor and sensory functions. This includes pulse, blood pressure, respiration rate and oxygen saturation. The patient is considered recovered if responding to voice commands, appears oriented to self, and has stable vital signs. The drains and wound are checked and noted for the amount and type of drainage. Post-operative nausea and vomiting are monitored to prevent pulmonary aspiration. Any concern about the patient’s condition should be brought to the attention of the anaesthetist immediately. The patient is discharged from the recovery room to the ward, with permission of the anaesthetist. Return to the ward and handover To ensure continuity of care during the post-operative period when the patient leaves the recovery room for the ward, there must be accurate handing over of the patient’s intraoperative and immediate post-operative details with up-to-date recording. Discharge criteria from the recovery room must be met regarding level of consciousness, blood pressure, colour and perfusion, muscle control and pain control.

Post-operative nursing Post-operative nursing involves the care and management of the surgical patient from the time he or she returns to the ward from theatre until discharge. Post-discharge or hospital-to-home care may also be included, depending on the type of operation the patient has undergone. Some surgical procedures, such as colostomy or amputation, require long-term follow-up in the community or on an outpatient basis.

Aims of post-operative care The aims of post-operative care are to meet the physical needs of the post-operative patient. These are the following: • Adequate ventilation and oxygenation 618

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• • • • • • • • • • •

Maintenance of circulation Maintenance of normal body temperature Maintenance of fluid, electrolyte and acid–base balance Elimination of waste products Relief of pain and discomfort during convalescence Promotion of wound healing Maintenance of adequate nutrition Promotion of adequate rest and sleep in order to facilitate healing and recovery Promotion of movement and exercise, leading to a return to full mobility Protection and safety during recovery and convalescence Prevention or early recognition and effective management of post-operative complications • The provision of ongoing support and reassurance for both patient and family • The promotion of optimum health by providing effective patient education and discharge advice, appropriate referral and follow-up.

Preparation of the environment The patient must be received into a clean post-operative bed. Many institutions require that the bed be warmed with an electric blanket, especially after major surgery. The nurse must ensure that the electric blanket is removed just prior to putting the patient into bed. The electric blanket constitutes a medico-legal hazard, in that a warming blanket may burn the patient. Working suction and oxygen must be available at the bedside, together with a suitable oxygen mask and suction apparatus. Suction and oxygen may be needed in case of emergency and it is for this reason that they are placed at the bedside. Observation and fluid balance charts must be ready at the bedside to record post-operative observations. A mouth tray and oral airway should be in readiness, as well as any other bed accessories (such as a kidney dish should the patient vomit, a drip stand, a floor stand for a urine bag, a baumanometer and pulse oximeter, linen savers) that will be needed, depending on the procedure. Receiving the patient from theatre The nurse receives the patient from the theatre staff and assesses the patient, as the condition of the patient on return from theatre will influence nursing care in the early post-operative phase. Before the patient is put into bed, the nurse should do the following: • Check the wound site and drains for amount and type of drainage. • Check the operation site for bleeding. • Note any reduced urinary output. • Record all patient interventions including the patient’s self-report of symptoms such as nausea and pain. • Report any concerns in writing in the patient’s notes and to a senior staff member. Nursing care during the later post-operative period Once the immediate post-operative phase is over, the patient will be more independent and able to do more for him- or herself, but will still require good nursing care and observation. 619

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Principles of nursing care during the immediate post-operative phase • Promotion of normal circulation • Promotion of adequate ventilation and oxygenation • Promotion of comfort and relief of pain • Maintenance of adequate nutrition and hydration • Promotion of normal elimination • Promotion of wound healing • Maintenance of normal muscle tone and mobility • Provision of psychological support.

• For the first 24 hours after surgery, the patient requires close monitoring of vital signs, respiration and level of pain. Pain control is essential to promote early mobilisation to prevent complications such as deep vein thrombosis and the psychological effects of anxiety and depression (Rothrock 2011: xx; Wulff & Cohen 2012: 16). In addition, the wound is assessed. and urine output is monitored. Pressure care is implemented and recorded. The patient is encouraged to move his or her feet, and is assisted to change position. The doctor’s orders will include oral intake and eventual mobilisation. • The nurse should continue to supervise deep breathing and coughing exercises. Once the patient is taking a full ward diet, the nurse should ensure that the patient takes a balanced diet rich in kilojoules, proteins and vitamins, which will aid the physiological processes of healing. • As convalescence progresses, the use of narcotic analgesics can be reduced and replaced by non-narcotic analgesics and ordinary comfort measures until the patient is entirely pain free and requires no analgesics. • Full mobility and self-care are encouraged. The patient may not, however, be able to take a full bath before removal of stitches to prevent the wound from becoming wet and soggy. A shower may be permissible, depending on the position of the wound. The nurse provides a decreasing amount of assistance, taking into account the type of surgery and the condition of the patient.

Preparation for discharge and health education Preparation for discharge is a very important aspect of late post-operative care to enable the patient and family to cope once the patient is discharged. The precise nature of the discharge advice depends on the nature of the procedure and whether any complications have occurred. Specific health education will be necessary at this stage if a permanent change in lifestyle is required, for example diet and colostomy care, care of other types of stoma, care of stumps, etc. General discharge advice should, however, cover the following aspects: • Diet: The patient is normally discharged on a full ward diet. The nurse must emphasise the importance of a balanced diet that is high in kilojoules, proteins and vitamins. If surgery results in any dietary restrictions, the patient must be fully aware of these and must be able to cope with them at home.

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• Medications: These must be taken as prescribed. It is important that the patient completes antibiotic courses commenced while still in hospital. • Exercise and mobility: This should include any limitations that may be necessary. A sensible pattern of rest and activity should be followed. The patient should not become overtired, and it is advisable to start with short periods of activity and build up. Strenuous physical exertion and sports are to be avoided until the surgeon gives permission for the resumption of these activities, which must take place slowly and progressively until full physical fitness is regained. • Self-care: If stitches/clips are still in situ at the time of discharge, the patient should not take a full bath until they have been removed. Ongoing care of the wound must be explained to the patient. • Problems: The importance of reporting any problems must be stressed. The patient should be advised about common problems and how to overcome them. • Follow-up visits: The patient should know when follow-up visits to the surgeon will take place, and the nurse should emphasise the importance of these visits. • Other matters: Other matters that may need to be dealt with include resumption of sexual activity, pain management and wound care. If the stitches have not been removed at the time of discharge, the patient must know when to return to have them removed. • Practical aspects: Practical aspects such as sick certificates may need to be explained. The patient must not return to work before the surgeon gives permission. Usually sick certificates are made out at the follow-up visit when the surgeon tells the patient that he or she may return to work.

Post-operative complications Early post-operative phase Shock and haemorrhage

• Anaesthetic agents depress the myocardium, leading to hypotension and circulatory inadequacy. When identifying hypotension due to myocardial depression, it is important to eliminate all other common causes of post-operative shock, such as bleeding. Myocardial depression and resulting hypotension are treated with inotropic agents such as Dopamine or Dobutrex. • Body fluids are lost at the time of surgery. It is also possible for the patient to actively bleed from severed blood vessels in the immediate post-operative phase. Bleeding should be suspected when unexplained restlessness is present in the patient; later the patient will develop hypotension, tachycardia, pallor and poor skin perfusion with cold clammy extremities. Post-operative bleeding may be external, in which case blood loss from the wounds and any drains will be visible. Bleeding may also be internal, in which case visible blood loss is absent, but the clinical manifestations of shock and haemorrhage are present. If the nurse suspects bleeding, the patient should be kept flat and the surgeon should be informed immediately. Intravenous fluids can be speeded up in order to replace fluid loss, and blood and plasma can be made ready in case the patient requires them. It is sometimes necessary to take the patient back to theatre to stop the bleeding. A new consent is not required, but the patient and family should be informed. 621

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• Re-distributive shock may also occur. Body fluids are lost during surgery. At the time and during the first hour or two after surgery, this fluid loss is not apparent because the peripheral vascular beds are constricted due to hypothermia, which maintains the blood pressure. As the patient’s body temperature returns to normal, however, these peripheral vascular beds dilate and the blood pressure drops because the actual circulating blood volume is insufficient to maintain the circulation. At this stage the patient shows the clinical manifestations of shock, even though the patient is not actively bleeding. This type of redistribute shock is treated with fluids. Often the patient requires a unit of blood or a unit of plasma in order to correct the problem. Dysrhythmias

Abnormal cardiac rhythms may occur post-operatively due to myocardial depression and sensitisation of the myocardium by anaesthetic agents. Patients who are particularly at risk are those with a pre-existing cardiac problem. At-risk patients should be closely observed after surgery and, if available, a cardiac monitor may be useful. If arrhythmias occur, they are treated with the appropriate anti-arrhythmic drug, such as lignocaine in the case of ventricular tachycardia. Pneumonia and atelectasis

Pneumonia and atelectasis are problems of immobility. Relatively immobile postoperative patients do not expand their lungs adequately, which leads to the collapse of portions of the lung, or atelectasis. Atelectasis is easily detected as an opaque area on chest X-ray, and for this reason such an X-ray should be done on all postoperative patients following major surgery. Secretions are increased due to the effects of anaesthetic agents, but pain and discomfort make the patient reluctant to cough these secretions up. These retained secretions invariably become infected, leading to pneumonia. Pneumonia and atelectasis can be prevented by effective deep breathing and coughing in the early post-operative phase. Once atelectasis has occurred, aggressive chest physiotherapy must be applied in order to re-expand the collapsed area of lung. Pulmonary infection is treated with appropriate antibiotics. Pulmonary infection is a very common cause of an increase in temperature post-operatively, and it is important for the nurse to be aware of this and report it. Paralytic ileus

Paralytic ileus involves a marked decrease in gastrointestinal tract muscle tone with the accumulation of fluid in the lumen of the gastrointestinal tract. This complication may follow bowel and abdominal surgery in which the intestines have been handled. Intraabdominal sepsis and peritonitis may also lead to paralytic ileus. The patient’s abdomen becomes distended and no bowel sounds are detectable. Vomiting, which is an effortless regurgitation of intestinal contents, occurs if the fluid accumulation is significant. The patient must be kept nil per mouth if paralytic ileus is present. Nasogastric suction is used to reduce fluid levels, and fluids and nutrition are maintained through intravenous therapy. Paralytic ileus following handling of the intestines will usually recover spontaneously. If the paralytic ileus is due to intra-abdominal sepsis, the infection must be dealt with and the patient given an appropriate antibiotic.

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Deep vein thrombosis and pulmonary embolism

After surgery, the blood clots more easily. This is a protective mechanism and it is part of the healing process. If the patient is immobile, however, the blood may form clots in the blood vessels, particularly in the deep veins of the legs and pelvis where circulation is sluggish. Once formed, sudden movements may dislodge these clots. Such dislodged clots form emboli that travel in the bloodstream, ultimately becoming lodged in the smaller blood vessels of the lungs, occluding these vessels and causing infarction of lung tissue distal to the occlusion. A pulmonary embolism manifests with a sharp, stabbing chest pain accompanied by dyspnoea and hypotension. A large embolism may cause the sudden collapse and death of the patient. Subsequently the infarcted area of the lung becomes infected and gas exchange is reduced both by the infarction and the resulting infection. Statistically, a pulmonary embolism is most likely to occur on or about the seventh post-operative day. Early mobility and ambulation will prevent a large proportion of deep vein thromboses and pulmonary emboli. Both deep vein thrombosis and pulmonary embolism are treated with anticoagulants. In the case of pulmonary embolism, oxygen therapy is required. A large pulmonary embolism may necessitate mechanical ventilator support. Infection

Acute infection in the early post-operative phase is usually the result of massive contamination of the wound during the surgery itself. Such an acute infection often manifests itself in a persistently oozing wound, particularly if the fluid is sero-purulent, and it is very important for the nurse to check the condition of the wound regularly and to report if it is oozing. Other manifestations of acute wound infection include persistent pain in the wound, heat, swelling and abscess formation around the wound, as well as an early and significant increase in the patient’s temperature. Infection is treated with the appropriate antibiotic, and suitable antiseptics and dressings are applied to the wound.

Late post-operative phase Infection

Wound infection in the later post-operative phase is usually acquired in the surgical ward itself through poor aseptic dressing technique, cross-infection from other infected patients or contamination from other areas of the patient’s body. Clinical manifestations include pyrexia, pain, swelling and redness around the wound. as well as abscess formation in the area of the wound. This type of infection is also treated with antibiotics. Secondary haemorrhage

Secondary haemorrhage occurs around the seventh to the tenth post-operative day, and manifests as bleeding, often significant, from the area of the wound. Secondary haemorrhage is always due to infection, and the wound must be considered to be septic. The patient may have to go back to theatre in order for the bleeding to be stopped. Because such a procedure follows more than 24 hours after the initial surgery, new consent for surgery is required.

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Rupture of the wound

Rupture, or dehiscence, of the wound following removal of the sutures is also invariably a result of infection, although rupture without infection may occur in undernourished or grossly obese patients. Breakdown of the wound may involve only the superficial layers of the wound, but may involve all the layers with exposure of underlying organs and tissues. If it is an abdominal wound, a complete rupture may result in protrusion of the intestines through the ruptured abdominal wall. In the case of rupture of a surgical wound, the wound must be covered with sterile coverings. Soaking the covering in saline will keep the underlying structures moist, and limit fluid loss. If intestines are protruding through the wound, they may be gently replaced if this is possible without using force, and the wound covered in sterile cloths that have been soaked in sterile saline. The patient must be kept at bed rest and closely observed for the development of shock. The patient will need to return to theatre, on a new consent form, to have the rupture repaired. Complications of wound healing

Various complications of wound healing such as keloid and adhesion formation may follow surgery. Adhesions are most likely if there has been infection of the wound, although some people seem to have a predisposition for adhesion formation. Keloid formation is also more common following infection and inflammation, and is more common in dark-skinned and black individuals, as well as individuals with a genetic predisposition.

Complications due to anaesthesia Ventilator complications These may manifest as hypoxaemia or hypoventilation. All post-operative patients should receive 40% oxygen by mask to reduce the incidence of hypoxaemia. If the patient is slow to regain consciousness or appears to be hypoventilating, it may mean that the effects of narcotic analgesics have not been fully reversed, and the anaesthetist should be informed. Patients who will require mechanical ventilation for the first 12–24 hours post-operatively are usually transferred straight to the intensive care unit without reversal of the anaesthetic. Non-reversal of the anaesthetic in these patients helps to maintain sedation in the intensive-care unit. Pain Pain can be minimised by giving a pre-emptive dose of analgesia during the anaesthetic, by doing a regional/local anaesthetic block of the operative area, or by instituting patient-controlled analgesia. Children in the age group 2–13 years are unable to tolerate pain and thus need extra efforts to reduce their pain. Nausea and vomiting Patients often anticipate that they will feel some pain post-operatively, but nausea and vomiting are often more distressing than pain. Anti-emetics should be given prophylactically to all patients, especially those who have been given narcotic analgesics. Vomiting may lead to pulmonary aspiration. To prevent aspiration, the patient should be placed in the lateral or tonsillar position in the recovery room. 624

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Cardiovascular complications These could include hypotension or hypertension. Hypovolaemia may be masked by vasoconstriction while in the theatre and may only become apparent in the recovery room. The experience of pain may also increase sympathetic activity in the patient, causing hypo- or hypertension. Bleeding must be stopped. Shivering This may be as a result of the hypothermia or may be due to the action of inhalational anaesthetics. Although not a complication as such, shivering increases oxygen consumption. Patients must be given supplemental oxygen and be kept warm.

Essential health promotion and health education Many community clinics have a small theatre suite, and theatre staff are available to perform minor surgery or day surgery. In day surgery, the patient is admitted to the clinic and discharged home on the same day as the surgery. It is thus important to educate the patient and family about pre-operative preparation, keeping the patient nil per mouth as well as essential care post-operatively. Wounds, drains and sutures must be cared for at home, and family members must be taught how to do this. The patient and family also need to know when to bring the patient back and what complications to look out for. Small children are frequently terrified of surgery, and education of both the child and the parents is needed in the pre-operative period.

Health education aspects • The importance of allaying fear and anxiety through thorough pre-operative education regarding the nature of the surgical procedure as well as the experiences that the patient will undergo in the pre-, intra- and post-operative stages cannot be overemphasised. • The nurse and the surgeon should collaborate on this, with the surgeon doing the initial explaining and the nurse reinforcing this and explaining the routine aspects of surgical care such as deep breathing, coughing, leg exercises and the management of pain. • The pre-operative visit is of crucial importance. The theatre nurse has the opportunity to talk to the patient about what will happen in the operating theatre, and the patient has an opportunity to ask questions. This will allay fear and anxiety. • Discharge teaching is also important, covering such matters as wound care, diet, physical activities, return to work, medications and the reporting of any problems.

Conclusion Peri-operative nursing care is all-inclusive. It relates to surgical intervention and has three phases: pre-operative care, intra-operative care and post-operative care. Patients who undergo surgery have to be in good health to promote good health outcomes post-operatively. Pre-operative care entails ensuring that the patient is free from any forms of infection, is knowledgeable of chest and leg exercises and is well nourished. Even the patient’s psychological disposition needs to be in the correct frame. Patients 625

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need to sign an informed consent prior to surgery and although the obtaining of the consent is the responsibility of the attending surgeon, the nurse, in her capacity as the patient’s advocate, must ensure that the surgical procedure, and its benefits and risks are explained in full.

Suggested activities for students Activity 28.1 The student selects a surgical patient in one of the surgical wards and carries out a case study of this patient as follows: • The student should take the history of the patient, particularly of the surgical problem, and any surgical risk factors that may be present. • The student should follow pre-operative preparation and progress. • If possible, the student should seek permission to accompany the patient to theatre and to be present during the procedure. • During the procedure, the student should note the type of anaesthetic used, relevant details of the procedure itself, and progress in the recovery room. • Post-operative progress should include details of wound management and the progress of the patient’s wound healing. • Where possible, the student should arrange to give health education before the patient is discharged.

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Smeltzer, SC, Bare, GB, Hinkle, JL & Cheever KH. 2010. Textbook of Medical Surgical Nursing. Philadelphia: Lippincott. South African Nursing Council (SANC). 2014. Regulations Setting out the Acts and Omissions in Respect of Which the Council May Take Disciplinary Action. South African Nursing Council (SANC). Nursing Act (No. 33 of 2005). South African Nursing Council (SANC). 2013. Code of Ethics for Nursing Practitioners in South Africa. Pretoria: SANC. Available at: http://www.sanc.co.za/policies.htm South African Nursing Council. 1991 Regulations Relating to the Scope of Practice of Persons who are Registered or Enrolled under the Nursing Act, 1978. Government Notice R 2598 Pretoria: SANC. Spouse, J, Cox, CL & Cook, MJ. 2008. Common Foundation Studies in Nursing. 4th ed. New York: Elsevier. Strategic plan for maternal, newborn, child and women’s health (MNCWH) and nutrition in South Africa 2012–2016. Available at https://extranet.who.int/nutrition/gina/ sites/default/files/ZAF%202012%20MNCWHstratplan.pdf. (Accessed 2 January 2016). Sulmasy, DP. 2002. A bio-psychosocial-spiritual model for the care of patients at the end of life. The Gerontologist, 42, Special Issue III: 24–33. Sundeen, SJ, Stuart, GW, Rankin, AD & Cohen, SA. 1998. Nurse—client Interaction. 6th edition. St Louis, Missouri: Mosby. Swart, R & Dhansay, A. 2008. Nutrition in infants and preschool children. In Steyn, NP & Temple, N. (eds). Community Nutrition Textbook for South Africa: A Rights-based Approach. Tygerberg, Cape Town: South African Medical Research Council Chronic Diseases of Lifestyle Unit. Teasdale, G & Jennett, B. 1974. Assessment of coma and impaired consiousness: a practical scale. Lancet, 13(2):81–4. Turner, AM, Stavri, Z, Revere, D & Altamore, R. 2008. From the ground up: Information needs of nurses in a rural public health department in Oregon. Med Libr Assoc, October, 96(4): 335–342. doi: 10.3163/1536-5050.96.4.008. Van Dyk, A. 2012. HIV and AIDS Education, Care and Counselling. A Multidisciplinary Approach. 5th ed. South Africa: Pearson. Vorster, HH, Badham, JB, Venter, CS. 2013. An introduction to the revised food-based dietary guidelines for South Africa. South African Journal of Clinical Nutrition, 26(3):S1-S164. Walsh, SH. 2004. The clinician's perspective on electronic health records and how they can affect patient care. BMJ, 328(7449): 1184–1187. doi: 10.1136/bmj.328.7449.1184. Watson, R. 2013. Nursing research in the 21st century. Journal of Health Specialities, 1(1): 13–18. Western Cape Department of Health Directorate: Comprehensive Health Programmes, Subdirectorate: Nutrition. 2011. Guidelines and Standard Operating Procedure for Growth Monitoring and Promotion in the Context of the Road to Health Booklet. Cape Town: Government Printer. Western Cape Government Health. 2014. Practical Approach to Care Kit (PACK): Primary Care Guideline for Adults. Cape Town: Government Printer. White, L, Duncan, G & Baumle, W. 2010. Foundations of Adult Health Nursing. 3rd ed. Available: http://www.cengage.com/highered. (Accessed 2 January 2016).

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Wiskow, C. 2003. Guidelines on Workplace Violence in the Healthcare Sector. ILO/ ICN/WHO/PSI Joint Programme on Workplace Violence in the Health Sector. ILO/ ICN/WHO/PSI: Geneva. Available: http://www.who.int/violence_injury_prevention/ violence/interpersonal/en/WV_ComparisonGuidelines.pdf. (Accessed 2 January 2016). World Health Organization. 1946. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. World Health Organization. 2000. Multimodal hand hygiene improvement strategy and an implementation toolkit. Available: http://www.who.int/gpsc/en/. (Accessed 2 January 2016). World Health Organization. 2009. Patient Safety, WHO Guidelines on Hand Hygiene in Health care. Available: http://whqlibdoc.who.int/publications/2009/9789241597906_ eng.pdf. (Accessed on 15 September 2014). World Health Organization. 2013. Countries, South Africa. Available from from: http:// http://www.who.int/countries/zaf/en/. (Accessed 2 January 2016). Wulff, T & Cohen, MA. 2012. Knowledge and clinical practice of nurses for adult postoperative orthopaedic pain management. Unpublished Master’s of Nursing thesis, Stellenbosch University. Younas, A & Sommer, J. 2015. Integrating nursing theories into practice: Virginia Henderson’s need theory. International Journal of Caring Sciences, 8(2).

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Index Page numbers in italics point to figures and tables

A abbreviations  222–223 abdominal girth of patient, measuring  431 abnormal cardiac rhythm  349 accountability 70–71 acid-base balance  424–425 disturbances 441–442 acne vulgaris  550, 553–554 active exercise  458 activities of daily living  455–456 acute respiratory failure  320–322 adaptation, need for  105 adequate intake of food  407 administrative support, nurses’ need for 260 adolescents, nutrition  395 adults, nutrition  395–396 adverse conduct  48–49 advertising 49 advocacy 28 African concept of time  128–129 African Religion see Traditional African Religion agent-host-environment model of health 19–20 airborne precautions  237 alcohol, and sleep  520 allergies, side effects and adverse reactions to medication  223 altered sensory perception, and patient risk 216–217 alternative therapies  398 amulets and charms  140 anaesthesia, complications due to  624–625 analysis of needs and diagnosis of discharge plans  198 anthropometric measurements  400–403 anxiety of patient undergoing surgery  612–613, 615 apex beat, position  343 arteries 341 arterioles 341 artificial eyes  575 asceticism 62

assertive behaviour  284–288 assessment of patient  see also patient assessment and discharge plans  198 atelectasis, after operations  622 athlete’s foot  551 auscultation and respiratory assessment 310–311 autonomy  68, 106 awareness impaired patient, risks  217

B balanced home life, nurses’ need for  261 barriers to communication  278–279 basic nursing care in the home  205–207 basic physical care at home  199 bed baths  572–574 bedrest 462–476 complications of  466–476 positions in bed  463–466 behavioural techniques to reduce pain 532–533 belief systems of major religions  117–134 beneficence 67–68 bereavement counselling  200 bioavailability of nutrients  386–387 biochemical analysis and nutritional status 403 biochemical tests of urine  489 biographic information about patients  198 biomedical paradigm  142 bio-psychosocial needs, summary  107 bio-psychosocial theories  100–102 black nurses, training  9 bladder problems  509–511 blood gas results important values  442 metabolic acidosis  444 metabolic alkalosis  446 respiratory acidosis  443 respiratory alkalosis  445 blood loss from wounds  564 blood pressure  342–343, 344

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problems 345–349 body fluid distribution  421 body image, response of patient undergoing surgery  607 body lice  551 body temperature measurement 356–358 normal variations  356 body temperature regulation  355–356 common clinical problems  358–363 continuous arterio-venous rewarming  363 fever 358–359 heat stroke  361 hypothermia 362–363 malignant hyperpyrexia/ hyperthermia 360 pyrexia 358–359 rigors 359–360 bowel washouts  504 brain, reticular activating system  525 breast-feeding mothers, nutrition  390–392 bronchoscopy 313 Buddhism 124–126 bullying in the health sector  76

C caffeine, and sleep  520 calcium deficit  438–441 calcium excess  437–438 calluses 550 candidiasis 551 capillaries 342 carbohydrates 368–371 cardiac failure  346 cardiovascular complications due to anaesthesia 625 cardiovascular system and bedrest complications  467–468, 472–473 response of patient undergoing surgery 604–605 caring for the caregiver  207 carpo-pedal spasms  439 cellphone use  90 central nervous system, functions  584–585 cerebro-vascular accident  346 chain of infection  234

chest radiography  313 children nutrition 394–395 patient assessment  169 cholesterol 374 Christianity 116–118 Circadian rhythm  516 circulation, need for  102 circulatory system common problems  345–349 function of  340–343 nursing assessment  343–345 civil law  28 clinical governance and clinical care, patient safety  214 closure of wounds  562 Code of Ethics for nursing practitioners in South Africa  51 codes of ethics in nursing  80–83 cognition, need for  105 cognitive distortions  113–114 cognitive functions, higher  585 collaborative, comprehensive and/or alternative healthcare provision 143–144 collective action, need of nurses  266–268 collective identity need of nurses  257 collegial support systems, need of nurses 260 colonic stimulants  503–504 comfort, need for  104 common respiratory problems  see respiratory problems, common communication  see also life skills assertive vs aggressive behaviour in conversations 285 barriers to, potential  278–279 in a cultural context  144–146 factors that influence  275–276 forms of  277–278 functions  245–247 (see also health communication) in healthcare settings  245–247 need for  107 and patient risk  218 principles 244–245 process of  276–277 communities, identification of  157–158

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Index

community assessment meaning of  150–153 process 156–157 and research  153–160 steps 157–160 community diagnosis  160–161 community health workers, role in homeand community-based care  203 community, meaning of  150 complementary therapies  398 complex carbohydrates  369 confidentiality 49–50 confidentiality and access to patient records 92–93 confinement to bed  see bedrest conflict management  291–293 confused patients  592–595 consciousness level assessment  589–590 consent for surgery  614 constipation 496–497 prevention 502–505 constitution 29 contact lens care  575 continuous positive airways pressure (CPAP)  329–330 contractual obligations in the workplace 37–38 corns 550 cough 314–318 counselling and interviewing  296–297 criminal law  29 cross-infections, minimising  220 cultural issues in healthcare  138–141 cultural perspectives on health and illness 141–142 culture 137–138 cyanosis 320

D Dark Ages of nursing  6–7 data collection, analysis and interpretation 156 death dying and disposal of bodies, and culture 140 Traditional African Religion  130–131 debridement of wounds  562 decision making  279–281 deep vein thrombosis after operations  623

defecation  see also faeces abnormalities 496–499 constipation 496–497 diarrhoea  498, 505 facilitating regular  500–502 factors that influence  495–496 faecal impaction  497–498 flatulence  498–499, 505 incontinence, faecal  498, 505 defence mechanisms of patients undergoing surgery  607 definition of a problem  154 definitions of nursing  10–11 dehiscence of wounds  564 after operations  624 delirious patients  592–595 demographic data  151–152, 158 dentures, care of  576–577 dermatitis 551 dermatitis in the nappy area  554 diagnostic tests  173–178 fluid, electrolyte and acid-base balance 427 pulmonary function  312–314 diarrhoea  498, 505 diet, and culture  138–139 diet history  404 diets used in hospital/care facilities 405–406 discharge and health education for postoperative patients  620–621 discharge plans, home- and communitybased care  196–202 discomfort assessment of  526–527 causes 526 comfort, facilitating  527–528 disposal of body parts, and culture 139–140 distraction techniques to reduce pain 532–533 disturbances of acid-base balance  441–442 doctors, role in home- and communitybased care  203 dressings 562–563 droplet precautions  236–237 drug therapy for pain  533–535 duty to take care  72

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dyspnoea 318–319 dysrhythmias 349 dysrythmias, after operations  622

E ecomaps 198 elderly patients, assessment  169 elderly people, nutrition  396–397 electrocardiogram (ECG)  344, 435, 436 electrolyte balance  422–424 electrolyte disturbances, major  440–442 electrolyte imbalances  431 electrolytes, need for  103 electronic management of patient information 96–98 elimination  see also faeces common clinical problems  500–512 constipation, prevention  502–505 defecation, facilitating regular  500–502 faeces  485–487, 494–499 functional bladder problems  509–511 gastrointestinal tract and formation of faeces 485–487 health promotion and health education, essential 511–512 incontinence 509–511 micturition, facilitating regular 500–502 normal physiological function  483–488 nursing assessment  488–500 nursing intervention  505–506 urethral catheter care  505–509 urine  483–485, 488–494 vomiting  487–488, 499–500 elimination and hygiene of home-care patients 205 elimination of waste products, need for 103 emotional problems, and sleep  520 emotional response to pain  525 emotional support for the terminally ill 200 empathy 288–291 employer, other recognition need of nurses 258–259 encouragement recognition need of nurses 258 endotracheal tubes  332–333

enemas 504 enteral nutrition  408–409 environmental communication  278 environmental factors, and mobility 456–457 environment, and sleep  520 epidemiological data  152–153, 158–159 eschar tissue formation  564 essential health literacy  32 ethical decision making  68–69 ethical dilemmas  79 ethical principles in nursing  67–68 ethical responsibility of the nurse  68–71 ethics 63–67 ethos 67 and informed consent  156 morals 65 science of  63–65 values 65–67 evidence-based practice, patient information management  89 exercise benefits 455 need for  103 and sleep  520 exploitation 49 eyes hygiene and grooming  571, 575 and hypertension  346

F facemasks  324–329 faecal impaction  497–498 treatment 504–505 faecal incontinence  505 faecal softeners  503 faeces  see also defecation; elimination characteristics 494–495 formation in gastrointestinal tract 485–487 specimens, obtaining  495 falls 225 family hierarchy and lines of communication, and culture  139 fats and oils  374–376 fever 358–359 fever blisters  552 fevers in home-care patients  207

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fibre 369 fibroblastic proliferation and angiongenesis 558–559 fidelity 68 financial interest  49 financial recognition need of nurses  258 flatulence  498–499, 505 Florence NIghtingale Pledge  81 fluid balance acid-base balance  424–425 electrolyte balance  422–424 maintenance 421–425 fluid electrolyte and acid-base balance calcium deficit  438–441 calcium excess  437–438 disturbances of acid-base balance 441–442 electrolyte imbalances  431 fluid volume deficit  427–429 fluid volume excess  429–431 hypercalcaemia 437–438 hyperkalaemia 434–435 hypernatremia 431–433 hypocalcaemia 438–441 hypokalaemia 435–437 hyponatremia 433–434 intravenous therapy  449–450 metabolic acidosis  444–445 metabolic alkalosis  446–449 nursing assessment  425–427 physical assessment  425–427 potassium deficit  435–437 potassium excess  434–435 respiratory acidosis  443 respiratory alkalosis  445–446 sodium deficit  433–434 sodium excess  431–433 fluid, electrolyte and acid-base balance, diagnostic tests  427 fluids, need for  103 fluid volume deficit  427–429 fluid volume excess  429–431 fluid/water 385–386 folk image of nursing  5 food adequate intake  407 handling and processing  387 safety and hygiene  399

fortified bread and maize flour  377 functional bladder problems  509–511 functional thought  283–284 fungal infections of the skin  551

G gastrointestinal system, response of patient undergoing surgery  605 gastrointestinal tract, and formation of faeces 485–487 gastrointestinal tract system, and bedrest complications  471, 476 general health, and patients’ ability to cope with surgery  608–609 genital hygiene  577 genitalia, hygiene and grooming  572 genito-urinary system, and bedrest complications  470, 477 genograms 198 Glasgow Coma Scale  589–590 glycaemic index  371 Government Notice R767  see professional conduct of nurses, regulations Government Notice R2598  43–46 gowns, masks and gloves  221–222 growth and development, and mobility 456

H haemoptysis 320 haemorrhage after operations  621–622, 623 management of  348–349 wounds 564 hair assessment 546 hygiene and grooming  570–571 washing 574–575 hand hygiene  237–239 handling and processing of food  387 hands and nails, hygiene and grooming 570 hand washing  239–240 head lice  551, 555 health and nutrition  387–390 health-belief model  20 health communication functions 245

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key features  245–247 theraputic relationships  247 health education  see also patient teaching comfort, promotion  536 diabetics 243 factors impacting on  244 hearing impaired patients  582 and home- and community-based care 193 laxative abuse  511–512 pain 536 for patients having operations  625 as patients’ right  136, 243 on post-operative discharge  620–621 skin care  552–555 and traditional healers  144 visually impaired patients  582 health-ill-health continuum and the role of nurses 18–19 health team, nurses’ need for support from 260 hearing aids  576 hearing, assessment  586–587 hearing impaired patients  591–592 heart 341 heathcare delivery systems approaches  23 heat loss via skin  354–355 heat production  353–354 heat stroke  361 Henderson, Virginia, nursing theories 13–14 herpes simplex (Type 1)  552 herpes zoster  552 higher cognitive functions  585 Hinduism 122–124 historical perspectives on nursing  4–10 black nurses, training of  9 images of nursing  5–7 South Africa, after 1950  9–10 in South Africa before 1900  7–9 in South Africa in the 20th century  9 history taking diet 404 fluid electrolyte and acid-base balance 425 mobility 458 patient assessment  166–169 of patient undergoing surgery  610

respiratory function  306–307 skin 543–545 wounds 560 HIV/AIDS patients, nutrition for  397–399 holistic paradigm  142 Homan’s sign  472 home- and community-based care 193–207 advantages of  195–196 defined 194 discharge plans  196–202 essential elements  194–195 goals of  195 provision of  204–207 team involved  202–203 terminal care  207 home assessment  201 home life, nurses’ need for balance  261, 281 hospice care  207 hospital-acquired infections  235–236 humanistic existentialism  61–62 human rights  72–73 humidification systems in oxygen therapy 330–331 hydration of home-care patients  205 hygiene and grooming bed baths  572–574 common clinical problems  572–580 dentures, care of  576–577 ear care  576 eye care  575 eyes 571 genital hygiene  577 genitalia 572 hair 570–571 hair washing  574–575 hands and nails  570 meaning of hygiene  568–569 mouth and teeth  571 mouth care for unconscious and seriously ill patients  577 nasal care  576 in neonates and infants  578–580 nursing assessment  569–572 oral hygiene and mouth care  576–577 in patients unable to help themselves 572–574

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Index

skin 570 sulcular technique  577 hygiene, need for  104 hygiene practices, and culture  139 hypercalcaemia 437–438 hyperkalaemia 434–435 hypernatremia 431–433 hyperpyrexia/hyperthermia, malignant  360 hypersomnia 521 hypertension 345–347 hyperventilation 445–446 hypervolaemia 429–431 hypocalcaemia 438–441 hypotension 347–349 hypothermia 362–363 hypotheses 155 hypovolaemia 427–429

I idealism 59–60 ideal self  274 illness and disease  20–21 images of nursing  5–7 impairment of awareness, and patient risk 217 incident reports  95–96 incontinence, faecal  498, 505 indemnity 29 industrial action  53–54 infants and neonates, hygiene and grooming 578–580 infants, nutrition  392–394 infection control  219–222 home care  206 infection control in the unit  see pathophysiology of infection infection-control principles, psychophysiology of infection  236 infection-control standards and guidelines, pathophysiology of infection  236 infections after operations  623 wounds  561, 564 infestations (head and body lice)  551 inflammation 558 information management  see patient information management; record keeping

information management systems, standards for  88 informed consent  77–79 and ethics  156 insoluble fibre  369 insomnia 521 inspection skin 545 wounds 560 inspection or observation in patient assessment 170–171 integumentary system, and bedrest complications  468–469, 473–474 International Council for Nurses (Code of Ethics for Nurses  81–82 inter-operative care  615–616 inter-professional recognition need of nurses 259 interventions in communities  161–162 interviewing and counselling  296–297 interviews in patient assessment  167–169 intravenous therapy  449–450 inyangas 132–133 Islam 121–122

J Johari Window  271–272 joint movements  459–462 Judaism 118–120 justice 68

K keloid formation in wounds  564 key ethical considerations  31 King, Imogene, nursing theory  15–16 kitting of clothes  229

L laboratory analysis and nutritional status 403 laboratory studies for patient assessment 178 laboratory tests of urine  489–490 Labour Relations Act 66 of 1995 (LRA) 263–264 lactating mothers, nutrition  390–392 Lamp in the pledge of service, meaning  82 large intestine, anatomy  487

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legal framework  see also Code of Ethics; professional associations and organisations contractual obligations in the workplace 37–38 disciplinary steps by Nursing Council 46–54 Government Notice R767  46–54 Government Notice R2598  43–46 industrial action  53–54 legal recognition, importance of  37 National Health Act 61 of 2003  38–39 Nursing Act 33 of 2005  39–43 professional conduct of nurses, regulations 46–54 professional indemnity  53 regulations, codes and rules relating to nursing practice  43–50 scope of practice regulations  43–46 social contract  36–37 trade unions  51–52 lesions 546 liability  29, 70 life cycle stages and the role of nurses 16–18 life skills  see also communication assertive behaviour  284–288 attributes 271–275 conflict management  291–293 decision making  279–281 empathy 288–291 interviewing and counselling  296–297 problem solving  281–284 stress management  293–294 time management  294–296 lifestyle and patient risk  217 response of patient undergoing surgery 608 lipids 374–376 literature reviews  154–155 local anaesthetics  535 logrolling a patient  477–478 lung scans  313

M macronutrients  see also nutrients carbohydrates 368–371

fats and oils  374–376 lipids 374–376 proteins 371–373 magic 131 magico-religious paradigm  141–142 magnetic resonance imaging  178 malignant hyperpyrexia/hyperthermia  360 malnutrition in the elderly  396 manual resuscitation bags  334–335 masks, gowns and gloves  221–222 Maslow, Abraham, bio-psychosocial theories 101–102 meaningfulness, need for  107–108 meaning of nursing  10–11 measurement body temperature  356–358 of electrical activity  174 of vital signs  173 mechanisms of heat production and heat loss 353–355 medical asepsis  237–239 medication allergies, side effects and adverse reactions 223 dosages 223 knowledge of the drug administered 223 safe administration  222–224 safe storage and control  224 and sleep  520 types of orders  222–223 wounds 563 medications, and patients’ ability to cope with surgery  609–610 medicine men and women  132–133 medico-legal considerations  31 mental health, of home-care patients 205–206 mental state assessment 588–590 and patients’ ability to cope with surgery 609 mentors, needs of nurses for  259 metabolic acidosis  444–445 metabolic alkalosis  446–449 metabolism, response of patient undergoing surgery  606 micronutrients  see also nutrients

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Index

minerals 381–385 supplementation 398 vitamins 376–381 micturition  485, 500–502 military image of nursing  6 minerals 381–385 mobility factors affecting  456–457 need for  103 nursing assessment  457–458 and patient risk  217 mobility and exercise need  see also bedrest activities of daily living  455–456 joint movements  459–462 of patient, meeting  458–462 models for nursing the individual, family or community  16–23 modern nursing  7 moles 546 money and valuables  229 morbidity 152–153 mortality 153 motor function assessment 587–588 control 585 mouth care  576–577 hygiene and grooming  571 for unconscious and seriously ill patients 577 moving patients  477–478 musculoskeletal system and bedrest complications  469, 470, 475–476 response of patient undergoing surgery 606

N nails, assessment  546–547 nappy rash  554 narcolepsy 521 nasal cannula  324 nasal care  576 National Health Act 61 of 2003  38–39 national health system  24–25 naturalism 59 nausea, due to anaesthesia  624 needs of nurses identity 256–257

protection of rights  261–268 recognition 258–259 rights, recognition  259 support 259–261 negligence  30, 47–48 neonates and infants, hygiene and grooming 578–580 nephron and urine formation  484 nervous system, response of patient undergoing surgery  606–607 Nightingale, Florence, nursing theories  13 non-communicable disease patients, nutrition for  399–400 non-governmental organisations (NGOs) 26 non-healing of wounds  564 non-steroidal anti-inflammatory drugs (NSAIDS) 535 Norton scale  474 NREM sleep  517 nuclear techniques, patient assessment  177 nurses interface with different cultures  144 role in home- and community-based care 202–203 role within multidisciplinary team, cultural perspective  146–147 Nursing Act 33 of 2005  39–43 nursing as a service to humankind  71–79 nursing assessment circulatory system  343–345 sensation, perception and cognition function 585–590 skin 542–547 nursing diagnoses related to unmet oxygenation needs  335 nursing interventions, sleep promoting 521–522 nutrients  see also macronutrients; micronutrients bioavailability 386–387 in food, factors affecting  386–387 nutrition and health  387–390 for HIV/AIDS patients  397–399 of home-care patients  205 interventions 397–398 and life cycle  390–397

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and mobility  456 need for  103 for non-communicable disease patients 399–400 nutritional status, assessment  400–404 problems, common  410–416 and skin health  548–549 and sleep  520–521 for TB patients  397–399 nutritional care plans  404–410 nutritional outcomes, evaluation  410 nutritionists, role in home- and community-based care  203

O odours of wounds, identification  560 oils and fats  374–376 operating room, preparation  616–618 opioids 534 oral health  395 oral hygiene  576–577 Orem, Dorothea, nursing theory  14–15 orophangeal airways  331–332 oxygen need  102  see also respiration oxygen therapy  322–335  see also respiratory problems, common artificial airways  331–335 delivery systems  323–330 general principles  322–323 humidification systems  330–331 nursing implications  335

P pain see also discomfort assessment of  528 behavioural techniques to reduce 532–533 clinical signs and symptoms  528 distraction techniques to reduce 532–533 drug therapy  533–535 due to anaesthesia  624 emotional response to  525 functions and importance  522–526 home care, relief  200, 207 other supportive therapies  535–536 patients who cannot communicate  530 perception of  525–526

physiology 522–523 radiation therapy  535 rating scales  529, 530 relief of  530–532 response of body  525–527 responses to  528–529 specific objectives  522 stages of  525 stimuli, types of  523 threshold 525 tolerance 525 types of  523–524 wounds 563 palliative care  199–200 palpation patient assessment  171–172 respiratory assessment  309–310 skin 545–546 wounds 560 paralytic ileus, after operations  622 parenteral nutrition  409 participatory and action research  154–156 passive exercise  458–462 passive vs aggressive vs assertive behaviour  287–288 pathophysiology of infection airborne precautions  237 contact precautions  236 droplet precautions  236–237 hand hygiene  237–239 hand washing  239–240 infection-control principles  236 infection-control standards and guidelines 236 medical asepsis  237–239 surgical asepsis  239 patient advocacy  76–77 patient assessment auscultation 173 children 169 diagnostic tests  173–178 elderly patients  169 electrical activity, measurement  175 history taking  166–169 inspection or observation  170–171 interviews 167–169 laboratory studies  178 magnetic resonance imaging  178

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Index

nuclear techniques  177 palpation 171–172 percussion 172–173 physical examination  169–173 radiographic techniques  176–177 reasons for  165–166 special circumstances  168–169 systematic, guidelines for  174–176 tomography 177 ultrasonography 177–178 visualisation techniques  174 vital signs, measurement  173 patient-controlled analgesia (PCA) 534–535 patient education prior to discharge  200 patient information management  see also record keeping confidentiality and access to records 92–93 electronic 96–98 evidence-based practice  89 need to generate and maintain  91–92 nurse, role of  93–94 supporting information  89 patient safety  see also risks, identification and management clinical governance and clinical care 214 common safety issues  216–218 competencies for  215–216 factors affecting patients’ potential for accidents 216–218 general aspects, overview  212 international standards  215–216 national standards  213–214 and nursing  212–213 of person, reputation and possessions 228–229 planning, general principles  218 patients unable to help themselves, hygiene and grooming in  572–574 patients who cannot communicate, pain 530 patient teaching  247–252  see also health education evaluation 251–252 methods 248–251 planning 247–248

principles 247–251 record keeping  252 pediculosis 555 Peplau, Hildegard, bio-psychosocial theories 101 perception  see sensation, perception and cognition percussion patient assessment  172–173 respiratory assessment  308–309 peri-operative nursing  see also surgery anaesthesia, complications due to 624–625 consent for surgery  614 discharge and health education, preparation for  620–621 early post-operative complications 621–623 environment, preparation  619 essential health promotion and health education 625 inter-operative care  615–616 late post-operative complications 623–624 in later post-operative period  619–620 nursing care of patient in recovery room 618 nursing management of patient undergoing surgery  611–618 operating room, preparation  616–618 post-operative complications  621–624 post-operative nursing  618–621 pre-operative nursing  611–613 preparation of patient in the ward 613–615 receiving patient from theatre  619 return to ward and handover  618 special needs of patient, nursing assessment 610–611 surgical risk factors, modification  613 personal identity need of nurses  256–257 personal support system, nurses’ need for 260–261 philosophical basis of nursing  58–59 philosophical schools of thought  59–62 physical assessment fluid electrolyte and acid-base balance 425–427

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of mobility  457–458 physical assessment of patients, for home care 204 physical examination patient assessment  169–173 respiratory function  307–311 physical needs of patients  102–105 physical support systems at work, need for 259 physiology of pain  522–523 physiotherapists, role of  478 pinch test  426 pitting of skin, on pressure  426 planning nursing care  182–190 activities involved  183–188 goals and outcomes  184–185 nursing care plans  186–189 nursing interventions, selecting 185–186 priority setting  184 planning of discharge plans  198–199 pneumonia after operations  622 poisons 224–225 polysaccharides 369 populations and samples  156 positions in bed  463–466 post-operative complications  621–624 postural drainage positions  316 potassium deficit  435–437 pragmatism 61 pregnant mothers, nutrition  390–392 pre-operative nursing  611–613 prescribed limitations, on mobility  457 prescriptions for medication  47 pressure areas, assessment  547 pressure areas of the body  470 primary caregiver, role of  202 private law  28 private sector healthcare system  25–26 problem solving  281–284 proclamation 30 professional associations and organisations  51, 52 professional colleagues, nurses’ need for support from  260 professional conduct of nurses  35–36 adverse conduct  48–49 advertising and touting  49



confidentiality 49–50 exploitation 49 financial interest  49 negligence 47–48 professional secrecy  49–50 regulations  43–46, 46–54 relationship with other colleagues & health professionals  50 relations with the Council  50 professional indemnity  53 professionalism, meaning of  33 professional secrecy  49–50 professional status of nursing  32–33 criteria for recognition as a profession 34–35 professional status of nursing and midwifery in South Africa, criteria 33–35 proteins 371–373 psoriasis  551, 554–555 psychological assessment of patients, for home care  204 psychological issues, and bedrest  471, 476 psychological preparation, of patient undergoing surgery  612 psychophysiology of infection chain of infection  234 hospital-acquired infections  235–236 mode of transmission  234–235 risk factors  235 psychosocial, cultural and spiritual aspects, response of patient undergoing surgery 608 psychosocial needs of patients  105–107 public healthcare system  25 pulmonary angiography  314 pulmonary embolism after operations  623 and bedrest complications  467–468 pulse 343–344 pulse oximetry  312, 344 pyrexia 358–359

R radiation therapy, pain  535 radiographic techniques, patient assessment 176–177 realism and theistic realism  60–61

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recommended dietary allowance (RDA)  387 record keeping  see also patient information management common problems  89 incident reports  95–96 legislation 86–87 manual 94 principles of  94–95 recovery room, nursing care of patient  618 referrals 200–201 regulations, codes and rules relating to nursing practice  43–50 relatedness, need for  106 relationship with other colleagues & health professionals 50 relations with the Council  50 religious expression, need for  108, 116 religious image of nursing  5–6 REM sleep  516–517 renal failure  346 research instruments  156 research methodologies  155 respiration  see also oxygen therapy breathing process  305 common respiratory problems  314–322 inadequate oxygenation of cells and tissues, causes  305–306 normal factors influencing  305 nursing assessment of respiratory function 306–314 respiratory acidosis  443 respiratory alkalosis  445–446 respiratory failure, acute  320–322 respiratory problems, common 314–322  see also oxygen therapy acute respiratory failure  320–322 cough 314–318 cyanosis 320 dyspnoea 318–319 haemoptysis 320 respiratory system and bedrest complications  466–467, 471–472 response of patient undergoing surgery 604 respite care  207 responsibilities of referring facilities 201–202

responsibility 71 rest, need for  104 restraint 593–594 restraints 226–228 return to ward and handover of surgical patients 618 rights of individuals  285–286 rights of nurses  75–76, 261–266 rights of the patient  73–75 rigors 359–360 ringworm 552 risks, identification and management  see also patient safety cross-infections, minimising  220 existing safety knowledge  218 falls 225 infections 219–222 medication, safe administration of 222–224 poisons 224–225 restraints 226–228 role-models, needs of nurses for  259 romanticism 62 Roper, Nancy, bio-psychosocial theories 101 routes of transmission of pathogenic organisms 219–220

S safe storage and control of medication  224 safety  see also patient safety need for  104 safety and hygiene of food  399 sanctity of life vs quality of life  79 sangomas 132–133 scabies 551 scarring, severe  564 scope of practice regulations  43–46 secondary haemorrhage, after operations 623 security, need for  104 sedation 594–595 self-acceptance 274–275 self-analysis 271 self-care deficit theory  14–15 self-concept 272–273 self-esteem and self-concept, need for  106 self-image 273–274

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self-knowledge 271–272 sensation, perception and cognition function central nervous system, functions of 584–585 common clinical problems  590–597 confused patients  592–595 consciousness level assessment 589–590 delirious patients  592–595 Glasgow Coma Scale  589–590 hearing, assessment  586–587 hearing impaired patients  591–592 higher cognitive functions  585 mental state, assessment  588–590 motor function  585, 587–588 nursing assessment  585–590 restraint 593–594 sedation 594–595 sensory function, assessment  586–590 sensory information, interpretation 584–585 unconscious patients  595–597 vision, assessment  586 visually impaired patients  590–591 sensory functions, other, assessment  587 sensory information, interpretation 584–585 sexuality and culture  141 need for  105 shingles 552 shivering due to anaesthesia  625 shock 348 after operations  621–622 sick role  22–23 side effects, allergies and adverse reactions, medication 223 simple analgesics  535 simple carbohydrates  369 skin anatomy 540–541 appendages 540–541 care 547–550 common problems, management 547–552 effects of loss of skin integrity  542 functions 541–542

hair, assessment  546 health education, general  552–553 heat loss via  354–355 history taking  543–545 hygiene and grooming  570 inspection 545 layers  541 lesions 546 moles 546 nails, assessment  546–547 nursing assessment  542–547 palpation 545–546 physical assessment  545–546 pressure areas, assessment  547 skin care products  552 specific problems  553–555 skin grafting  563 skin health, and nutrition  548–549 skin problems, of home-care patients  206 sleep and alcohol  520 amount necessary  516 and caffeine  520 characteristics 517 Circadian rhythm  516 disorders, common  521 and emotional problems  520 and environment  520 and exercise  520 facilitating 536 functions and importance  515–522 and illness  519 and medication  520 NREM sleep  517 nursing interventions  521–522 and nutrition  520–521 physiological changes  517–519 REM sleep  516–517 and rest, factors that influence  519–521 sleep cycle  516–517 stages 518–519 and temperature  520 and urinary excretion  519 sleep apnoea  521 social assessment of patients for home care 204–205 social contract in nursing and midwifery 36–37

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social factors that influence disease  21–22 social recognition need of nurses  258 social workers, role in home- and community-based care  203 sodium deficit  433–434 soluble fibre  369 South Africa healthcare delivery systems approaches 23 healthcare services  24–26 historical perspectives of nursing  9–10 national health system  24–25 non-governmental organisations  26 private sector healthcare system  25–26 public healthcare system  25 South African Food-Based Dietary Guidelines 387––390 South African Nurses’ Code of Service  82 special community nutritional services 409–410 special needs of patient for surgery, nursing assessment  610–611 spirits and forefathers, traditional African Religion 130 spiritual care  115–116 spirituality and religion  112 spiritual needs of patients  107–108, 112–115 spiritual support for the terminally ill  200 sputum culture  312 stages of growth and development and special needs  17–18 Standard Precautions  220–221 standard precautions and infection control  219, 221 standard precautions for home care  199 statutes 30 stimulation, need for  107 stress management  293–294 stress, response of patient undergoing surgery 603–604 supplementation and micronutrients  398 support groups, role in home- and community-based care  203 supportive care  30 surgery  see also peri-operative nursing classification of  602–603 consent for  614

effects on patients  603–608 indications for  602 patient’s ability to cope with  608–610 pre-operative nursing  611–613 stages 611 types of  602–603 surgical asepsis  239 SWOT analysis  160 syncope 347–348

T TB patients, nutrition for  397–399 technology in home care  207 teeth, hygiene and grooming  571 temperature and circulation  344 and mechanisms of heat production and heat loss  353–355 and sleep  520 temperature regulation, need for  103 terminal care, home- and communitybased care  207 theistic realism and realism  60–61 theories of nursing  11–16 common components  12 and the nursing process  16 therapeutic communication  278 therapeutic listening  291 time African concept of  128–129 and human life  129 timed get-up-and-go test (TGUGT)  225 time management  294–296 time of vomiting  499–500 tinea capitis  552 tinea pedis  551 tomography 177 touting  30, 49 t-pieces  327 tracheostomy tubes  333–334 trade unions  51–52 Traditional African Religion  126–133 death 130–131 ethics and morality  131 God, concept of  129–130 magic 131 medicine men and women  131–132 spirits and forefathers  130

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time 128–129 worship 127–128 tumours of the skin  551 turning a patient in bed  477

U ultrasonography 177–178 unconsciousness, causes  596 unconscious patients  595–597 Universal Precautions for Infection Control  see Standard Precautions ureteral catheter care  505–509 urinary excretion, and sleep  519 urinary system, response of patient undergoing surgery  605 urine abnormalities  491–493 biochemical tests  489 elimination 488–494 laboratory tests  489–490 normal, characteristics  490–491 samples, obtaining  493–494 urine output, and fluid balance  344 urine system  483–485

V veins 342 ventilator complications, due to anaesthesia 624 veracity 68 vicarious liability  30 vision, assessment  586 visualisation techniques  174 visually impaired patients  590–591 vitamins 376–381 volunteers, role in home- and communitybased care  203 vomiting due to anaesthesia  624



elimination  487–488, 499–500 nursing intervention  505–506 time of  499–500

W warts 552 water/fluid 385–386 women, role of, and culture  141 Wong-Baker FACES pain scale  529, 530 wound ruptures, after operations  624 wounds assessment 559–561 blood loss  564 care and promotion of healing  561–563 classification 556 cleaning 561–562 closure 562 complications 563–564 debridement 562 dehiscence 564 dressings 562–563 eschar tissue formation  564 haemorrhage 564 healing 557–559 history taking  560 infections  561, 564 inspection 560 keloid formation  564 medication 563 non-healing of  564 odours, identification  560 pain 563 palpation 560 remodelling and maturation  559 scarring, severe  564 skin grafting  563 types of  556–557

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