NUR111

• Reasons for changing a patient's position

  • To promote comfort and relaxation
  • To restore body function
  • To improve gastrointestinal function
  • To improve respiratory function
  • To prevent deformities
  • To relieve pressure and prevent strain
  • To stimulate circulation
  • To give treatments (range of motion exercises)
• Lying in bed for long periods of time

  • Causes muscles to become atonic and atrophy
  • Prevention of deformities will allow the patient to ambulate when his activity level is advanced
• Basic Principles in Positioning a PatientPositioning

  • Positioning: Supine
  • Positioning: Prone
  • Positioning: Sims/ Lateral
  • Positioning: Fowlers
• Positioning and re-positioning


  • Enhances patient comfort
  • Decreases to risk of pressure injuries
  • Encourages independence for clients
  • Reassuring for families
  • Time to be with the clients
  • Assessing the clients
• Personal hygiene practices


  Are influenced by: Culture, Religion, Environment, Developmental level, Health & energy, Personal Preferences
• Hygiene care involves care of

  • Skin
  • Hair
  • Nails
  • Teeth
  • Oral and nasal cavities
  • Eyes
  • Ears
  • Perianal and genital area
  • Shaving
• Assessing a client's self care abilities


  • Client's balance
  • Ability to sit unsupported
  • Activity tolerance
  • Co-ordination and muscle strength
  • Appropriate joint range of motion
  • Vision
  • Client's preferences
• Risk levels of body fluids

  • Low Risk: Saliva, Serosanguineous (haemoserous) drainage
  • Moderate Risk: Bile, Faeces, Urine, Purulent Exudate
  • High Risk: Gastric Drainage
• Purpose of bathing an immobile patient

  • To remove transient micro-organisms, body secretions, excretions & dead skin cells
  • To stimulate circulation
  • To eliminate unpleasant body odour
  • To produce relaxation and comfort for client
• Other Bathing Considerations

  • always gain consent.
  • remain patient decency.
  • prevention is best cure.
  • encourage patient to bath themselves.
  • equipment like shower chairs can be used.
• Causes of Infection


  caused by pathogens like bacteria, viruses, protozoa, or fungi getting into or onto body --> causes interruption with normal body functioning.
• Spread of Disease

  1. Contact --> skin-to-skin contact and contact with body fluids.
  2. Airborne/Droplet
  3. Contaminated objects, food, or fluid.
• Chain of Infection

  1. Causative Agent (pathogen)
  2. Reservoir
  3. Portal of Exit
  4. Mode of Transmission
  5. Portal of Entry
  6. Susceptible Host
• Spread of Disease- Contact

  1. Skin-to-skin Contact: transfer pathogens can occur through touch.
  2. Contact with body fluids: pathogens in saliva (kissing), urine, faeces, blood --> transferred via cuts, abrasions, or mucous membranes of mouth and eyes.
• Spread of Disease- Airborne

  • coughs and sneezes release airborne pathogens --> inhaled by others.
• Spread of Disease- Contaminated objects, food, or fluid

  • pathogens in person's body fluids may be spread from objects or through poorly stored foods and fluids.
• The Infectious Process- Stages

  1. Incubation Period
  2. Prodromal Stage
  3. Illness Stage
  4. Stage of Decline
  5. Convalescence
• Incubation Period

  • interval between entrance of pathogen into body and appearance of first symptoms --> feel a bit under the weather.
  • take time before microbes multiply enough to trigger symptoms of illness --> infected person may unwillingly be spreading disease during this time.
• Prodromal Stage

  • interval between onset of non-specific signs and symptoms to more specific symptoms --> fever.
  • during this time micro-organisms grow and multiply and host is more capable of spreading disease to others.
• Illness Stage

  • interval when patient manifests signs and symptoms specific to type of illness --> can be fatal if not checked.
• Stage of Decline

  • symptoms of illness improve as there is a decline in micro-organisms in the body.
• Convalescence Period

  • recovery period.
  • pathogen no longer replicates to increase its number.
• Why is infection control so important?

  • to avoid causing harm to people in nurse care.
  • to avoid catching an infectious disease ourselves.
• Standard Precautions

  • PPE --> gloves, gowns, eyewear, facemasks, hand hygiene.
  • safe handling and disposal of needles and sharps.
• Hand Care

  • cover cuts, abrasions, and burns with waterproof gauze.
  • use moisturiser x3 a day.
  • hand wash when hands are visibly soiled.
  • short nails and no nail polish/fake nails.
  • 5 moments of hand hygiene.
• Energy

  • Body obtains energy in form of kilojoules from carbohydrates, protein, fat, and alcohol.
  • Used for voluntary activities --> walking, talking.
  • Used for involuntary activities --> breathing, heart beating, digesting food.
• Factors Affecting Nutrition

  • Growth and Development.
  • Ethnicity and Culture.
  • Beliefs about food.
  • Personal Preferences.
  • Religious Practices.
  • Lifestyle.
  • Dietary Intolerances.
  • Finances.
  • Medications and Therapy.
  • Advertising.
  • Psychological Factors.
  • Alcohol Consumption.
• Factors Affecting Faecal Elimination

  • Development.
  • Diet & Fluid.
  • Activity.
  • Psychological Factors & Habits.
  • Pain.
• Faecal Elimination Problems

  • Constipation.
  • Faecal Impaction.
  • Diarrhoea.
  • Encopresis.
  • Flatulence.
• Urinary Elimination

  • urine collects in the bladder.
  • Adult bladder holds about 250-450mL of urine.
  • Infants and children hold smaller volume of 50-200mL.
• Factors Affecting Voiding (Urinary Elimination)

  • Development Factors.
  • Fluid and Food Intake.
  • Medications.
  • Muscle Tone.
  • Pathological Conditions.
  • Surgical and Diagnostic Procedures.
• Altered Urinary Elimination

  • Frequency and Nocturia.
  • Urgency.
  • Dysuria.
  • Enuresis.
  • Urinary Incontienence --> acute and chronic.
• Vitals

  • blood pressure
  • temperature
  • oxygen saturation
  • pulse/heart rate
  • respiration rate
• When to take Vital Signs

  • on admission/original assessment.
  • routine schedule, doctors request, etc.
  • change in patient's condition.
  • patient reports non-specific symptoms of physical distress.
  • anytime you want.
• Blood Pressure

  • normal range: 120/80 --> systolic = top number, diastolic = bottom number.
  • sites:
• Factors Affecting Blood Pressure
• Temperature

  • normal range: 36-37.9 C
  • sites: oral, tympanic membrane, auxiliary, temporal artery, rectal.
  • Febrile:
  • Afebrile:
  • Hyperthermia:
  • Hypothermia:
  • Pyrexia:
• Oxygen Saturation

  • normal range: 95%-100%.
  • <90% is life threatening.
  • measured percentage of oxygen the blood is carrying.

  Hypoxia:

  Cyanosis:
• Pulse/Heart Rate

  • normal range: 60-100 beats/minute.

  sites:

  1. Radial
  2. Temporal
  3. Carotid
  4. Brachial
  5. Femoral
  6. Popliteal
  7. Posterior tibial
  8. Dorsalis pedis
  9. Apical

  Bradycardia:

  Tachcardia:
• Respiration Rate

  • normal range: differs for age-groups (adult: 12-20).

  Tachypnoea:

  Bradypnoea:

  Apnoea: