NURSING AND MIDWIFERY COUNCIL OF

ZAMBIA
(Nurses and Midwives Act No. 10 of 2019)

DIPLOMA IN NURSING
eLearning Training Program

FUNDAMENTALS OF NURSING II

2022
SECOND EDITION
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording or otherwise without the permission of the
publisher.

Inquiries concerning reproduction, rights or requests for additional training material

should be addressed to:

The Registrar
Nursing and Midwifery Council of Zambia
Box 33521
Lusaka

Telephone N0: +260211221284

Fax +260211224893
Email: [email protected]

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FOREWORD

The Enrolled Nursing to Registered Nursing abridged programme is a diploma

programme that is aimed at upgrading all Enrolled Nurses in Zambia to Registered
Nurses.

This programme will be implemented using a blended approach of mostly distance

learning and some few weeks of face-to-face lectures. The Nursing and midwifery
Council of Zambia (NMCZ) introduced this programme with the aim of ensuring the
most needed health workforce (nurses) are maintained within their health facilities
while upgrading their professional qualifications.

These nurses as students for upgrade, will be required to meet their academic
requirements while they continue serving in their respective health facilities.
While undergoing this training programme, the students will be provided with e-
Learning Training Modules as well as hard copy modules to guide their training.

These students will be expected to follow the course schedule and be up to date with
the various training activities as outlined. The students of this programme will be
expected to attend the compulsory face to face lectures at the designated nursing
schools as indicated in the training schedule.

A supervising Lecturer will be allocated to each course to provide guidance and

monitor students’ progression. Students will only use email as official communication
with their supervising Lecturers. Any other form of communication will be deemed
unofficial.

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ACKNOWLEDGEMENTS

Nursing and Midwifery Council of Zambia would like to thank institutions and
cooperating partners that participated in the development of this documents.
Special thanks go to the content writers for putting together such formidable lecture
notes in an organised manner for students to use.

Dr. Aaron Banda

Registrar/ CEO
NURSING AND MIDWIFERY COUNCIL OF ZAMBIA

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ABBREVIATIONS AND ACRONYMS

ARVs - Antiretrovirals
CBC - Complete Blood Count
CBDs - Community Based Distributors
CBO - Community Based Organization
CHAZ - Churches Health Association of Zambia
CHWs - Community Health Workers
CPR - Cardiopulmonary Resuscitation
ECG - Electrocardiogram
EMS - Emergency Medical Services
ENT - Ear Nose and Throat
HIV - Human Immune Deficiency Virus
HPCZ - Health Professions Council of Zambia
ICT - Information Communication Technology
ICU - Intensive Care Unit
IMCI - Integrated Management Of Childhood Illnesses
LMUTH - Levy Mwanawasa University Teaching Hospital
MOH - Ministry of Health
SES - Socio-Economic Status
TBAs - Traditional Birth Attendants
UTH - University Teaching Hospital
VCT - Voluntary Counselling And Testing
WHO - World Health Organization

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TABLE OF CONTENTS
FOREWORD............................................................................................................... ii

ACKNOWLEDGEMENTS...........................................................................................iii

ABBREVIATIONS AND ACRONYMS........................................................................iv

TABLE OF CONTENTS..............................................................................................v

COURSE OVERVIEW................................................................................................ 1

Course Introduction.................................................................................................1

Course Learning Outcomes.....................................................................................1

Course Content....................................................................................................... 1

Course Assessments...............................................................................................2

Course Duration...................................................................................................... 3

Readings................................................................................................................. 3

UNIT 1: THEORIES, NURSING MODELS AND INTERACTIVE PROCESSES IN

THE CARE OF PATIENTS......................................................................................4

1.1. Unit Introduction............................................................................................... 4

1.2. Unit Learning Outcomes...................................................................................4

1.3. Definition of Key Terms....................................................................................5

1.4 Historical Perspective of Nursing Models........................................................6

1.5 The Nursing Process.......................................................................................26

1.6 Nursing Care Plan...........................................................................................34

1.7 Interactive Processes in Nursing Care..............................................................1

1.8 Documentation and Reporting.........................................................................13

1.9 Hospital Policies and Regulation.....................................................................23

1.10 Unit Summary................................................................................................25

1.11. Self-assessment Test...................................................................................26

1.12 References and Further Reading.................................................................26

UNIT 2: HEALTH CARE SYSTEMS..........................................................................28

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 2.1 Unit Introduction.............................................................................................. 28

2.2 Unit Learning outcomes...................................................................................28

2.3 Organisation of Zambia’s Healthcare System.................................................28

2.4 Healthcare Providers in Zambia......................................................................31

2.5 Factors Influencing Healthcare Services.........................................................33

2.6 The Right to Health Care.................................................................................36

2.7 Challenges in Healthcare Delivery System......................................................38

2.8 Unit Summary..................................................................................................41

2.9 Self-Assessment Questions.............................................................................42

2.10........................................................................................................................42

References and Further Reading..........................................................................42

UNIT 3: FIRST AID MANAGEMENT OF EMERGENCIES.......................................43

3.1 Unit Introduction.............................................................................................. 43

3.2 Unit Learning Outcomes..................................................................................43

3.3 Definition of Key Terms used in First Aid.........................................................44

3.4 Aims and Principles of First Aid.......................................................................44

3.5 Bandaging and Splinting..................................................................................45

3.6 Methods of Lifting and Transporting Casualties..............................................66

3.7 First Aid Management of Medical Emergencies..............................................79

3.8 Unit Summary................................................................................................127

3.9 Self-Assessment Questions...........................................................................128

3.10 References and Further Readings............................................................128

UNIT 4: DEATH AND GRIEF..................................................................................130

4.1 Unit Introduction............................................................................................ 130

4.2 Unit Learning Outcomes................................................................................130

4.3 What is Grief?................................................................................................130

4.4. Theories of Grief...........................................................................................131

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 4.5. Factors Influencing Grief...............................................................................137

4.6. Care for Terminally Ill and Dying Patients....................................................139

4.7. Death...........................................................................................................142

4.8 Unit Summary................................................................................................147

4.9 Self-Assessment Questions...........................................................................148

4.10 References and Further Reading...............................................................148

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COURSE OVERVIEW

Course Introduction
Welcome to Module 2 of the Fundamentals of Nursing course. This course is a
continuation from Fundamentals of Nursing Module I, which forms the foundation of
nursing practice. It is designed to equip you with the knowledge and skills you need
to practice as a nurse in the ward and community. This course prepares you to be a
critical thinker, client advocate, clinical decision maker, and client educator.
Fundamentals of Nursing Module II covers the concepts and models that will guide
you in planning nursing care and understand issues related to illness, wellness,
disease, health seeking behaviour and health practice. It also introduces you to the
basic skills that enable you to provide quality nursing care.

Course Learning Outcomes

Upon completion of this course, you will be able to:
1. Apply theories and models of nursing and the interactive
process in the care of patients
2. Describe the Health care systems in Zambia
3. Apply the principles of First Aid in the management of
emergencies
4. Apply theories of grief in the management of a dying patient
and the family.

Course Content
The course is divided into four (4) units as follows:
Unit One: Theories, nursing models and interactive process in the care of
patients.
In this unit, you will learn about the various nursing theories and models that guide
nursing practice. The unit also describes how to apply the nursing process as a tool
in the management of clients and patients. You will also gain valuable knowledge on

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how to communicate effectively with patients and the importance of documenting
your work on a daily basis.

Unit Two: Healthcare Systems

This unit will help you to understand how the healthcare system in Zambia is
organised and the factors that influence health care services. The unit also describes
the different cadres of health personnel that provide care to patients in health
facilities, and also explains the rights of patients to care and the challenges faced
by the healthcare system.

Unit Three: First Aid and emergencies

This Unit exposes you to the aims and principles of First Aid. You will learn the
different first aid techniques that you can use to manage accident victims, clients
with epileptic fits, cardiac arrest, and poisoning, among others. The unit also
provides you with valuable information on how to prevent fire in the ward and how to
evacuate patients from the ward (fire drills).

Unit Four: Death and Grief

This unit discusses theories of grief, factors influencing grief, death and dying and
how to care for the terminally ill and dying patient. You will also learn how to care for
the grieving family, how manage grief (grieving nurse) and also how to take care of
the body after death.

Course Assessments
Your work will be assessed in the following three ways:

1. Continuous Assessment 40%

 1 Test 20%
 Assignment 20%

2. Semester Examination 60%

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Course Duration
This course will take you 50 hours to finish the theory and 160 hours to complete the
practicals. You will be required to visit the skills lab at your nursing college to
practice the various procedures that are in your procedure manual book.

Readings
There is a section of references and further readings at the end of each unit. This
list gives details about books that are referred to in the unit, as well as other book
that provide additional information or other viewpoints related to the topics in the
units. You are encouraged to read as widely as possible during and after the course

The following are some of the reference books you may find helpful.
1. Ministry of Health, (1995). Health Management Information Systems, Lusaka,
Zambia.

2. Ngugi. E.N, (1984). Practical Notes on Nursing Procedures, African edition,

Churchill Livingstone, London.

3. Potter P. and Perry A, (2009). Fundamentals of Nursing, 7th edition, MOSBY,

Canada.

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UNIT 1: THEORIES, NURSING MODELS AND INTERACTIVE
PROCESSES IN THE CARE OF PATIENTS

1.1. Unit Introduction

In this unit, you will be oriented to the various nursing theories and models that guide
nursing practice. You will learn how to apply the nursing process as a tool that will
assist you in the management of the clients and patients. You will also learn how to
communicate effectively with patients and document your work and make you
understand why continuous documentation is very cardinal in the provision of care in
the hospital and community.

In this unit, we are looking at theories and models that have been developed over
the years and as you are aware, these were developed to assist healthcare givers in
providing systematic and organized nursing care.

You will come across terms that are new and somehow difficult, but you must not
give up. Once you understand them, you will find yourself using these terminologies
in your everyday conversations.

1.2. Unit Learning Outcomes

Upon completion of this unit, you will be able to:
1. Describe the historical perspective of nursing theories and
models
2. Apply the components of the nursing process to provide
individualised care
3. Develop a nursing care plan for your patients
4. Develop a helping relationship with your patients and
communicate effectively with members of the health care
team
5. Prepare accurate and detailed reports and documents
about all aspects of patient care.

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 6. Outline the main types of hospital policies and their
importance.

1.3. Definition of Key Terms

In this section, we will start by defining certain key terms so that you can understand
the information in this unit.

Theory: this is a set of principles on which the practice of an activity is based

(Lexico, n.d.).

Phenomenon: this is an aspect of reality that can be consciously sensed or

experienced (Meleis, 1997).

Nursing Theories: these are an organized framework of concepts and purposes

designed to guide the practice of nursing” (Nursing theory, n.d.).

Concept: this is an idea or mental image or label used to describe a phenomenon.

Model: this is a descriptive picture of practice that adequately represents the real
thing. (Pearson & Vaugan, 1987).

Nursing Model: this is a set of abstract and general statements about the concepts
that serve to provide a framework for organizing ideas about clients, their
environment, health, and nursing (Medical Dictionary, 2006)

Nursing Process: this is basically a problem solving approach to nursing that

involves interaction with the patient, making decisions and carrying out nursing
action on an assessment of an individual patient’s situation (Kratz, 1979)

Nursing Care Plan: this is a formal process that correctly identifies existing needs
and recognizes potential needs or risks ( Vera M, 2022).

As a way of reflecting on what you have just learnt, answer the following questions.
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 CHECKPOINT QUESTION NO. 1

1. Define the following terms

a. Model
b. Nursing model
c. Nursing theories
d. Nursing process
e. nursing care plan

Answers
a. Model: This is a descriptive picture of practice that adequately represents the real thing.
b. Nursing Model: This is a systematically constructed, scientifically based and logically
related set of concepts which identifies the component of nursing practice together with
the theoretical base of this concept and values required for the use of the practice.
c. Nursing Theories: Are reservoir in which findings related to nursing concepts, such as
comfort, healing, recovery, mobility, rest, caring enabling, fatigue and family care are
stored.
d. Nursing Process is basically a problem solving approach to nursing that involves
interaction with the patient, making decisions and carrying out nursing action on an
assessment of an individual patient’s situation.
e. Nursing Care Plan is a formal process that correctly identifies existing
needs and recognizes potential needs or risks

Having defined the key terms, we will now proceed to cover the historical
perspectives of Nursing Models.

1.4 Historical Perspective of Nursing Models

Nursing as a discipline has always tried to understand the human being and his
needs, in order to provide quality care. To help nursing achieve this understanding,
nursing models have been developed.

Nursing models have therefore emerged from the need to understand about people
and their needs. Nursing models take ideas from other fields of research and actively
use them to suggest a better way of nursing and caring for people.

To accomplish nursing goals of optimum (best) health and well-being, nursing

theories have been developed based on effective and efficient clinical therapeutics.

Theories can be either descriptive or prescriptive.

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 Descriptive theories are those theories that describe a phenomenon, an event
or a situation or relationship; identify its properties and its components and
identify circumstance under which they occur, for example, life process or person
-environmental interactions, among others.
 Prescriptive theories are those theories that address nursing therapeutics and
the consequences of interventions, for example, the nursing care plan.

1.4.1. Timeline of Nursing Theories

The following section give you a timeline of what has been done in nursing from
before 1950s to date, in order to arrive at the theories and models that are now being
used worldwide.

1. Prior to 1955 from Nightingale to Nursing Research.

The first theoretical approach was made by Florence Nightingale in the late 19 th
to 20th century to describe nursing focus and action in the Crimean war. This
highlighted the need for nursing education and exposed the unhealthy conditions
and environment endured by English soldiers during war situations.

2. Mid 1950s
American nurse educators prompted by the need to justify different levels of
nursing and therefore the need to develop curricular for different levels of nurse
educators.

3. 1955 to 1960: Birth of Nursing Theory

Columbia University Teacher’s College offered graduate programmes that
focused on education and administration.

4. 1961 to 1965: Theory of a National Goal in Nursing.

The Yale school of Nursing influenced by Columbia Teacher’s College,
considered nursing as a process rather than an end. They profoundly influenced
nursing research in the United States in the 1960s. Then in 1980, there was a
revival of that impact as nurses acknowledged Yale University’s strategies for

7
 theory development, evidenced by the recognition of Orland’s work and by the
paradigmatic shift in nursing research to phenomenology.

5. 1966 to 1970: Theory development was considered as a tangible goal for

academics.

6. 1971 to 1975: American Nurses Association

Recommended that theory development was the highest priority in the profession
and with the availability of the federal support, a symposium was sponsored by
Case Western University and was held as part of the nursing Science
programme.

7. 1971 to 1975: Theory Syntax

Nursing research focused on discussing and writing about research methodology.

8. 1976 to 1980: A Time to Reflect.

There was utilization of existing theory and development of further theory

9. 1981 to 1985: Nursing Theories Revival

Emergence of the domain concepts, acceptance of the significance of theory for
nursing and Doctoral programs in nursing were developed

10. 1986 to 1990: From Meta Theory to Single Domain Theory

There was increased writing related to concept development, knowledge
development and central nursing concepts.

1.4.2 Types of Nursing Models and Their Application

We are now going to talk about the nursing models and their application to the care
of patients in the hospital. You will cover the purpose of these nursing models in
nursing practice, their components and the types of models and their application.

Purpose of Nursing Models

The purpose of nursing models is to:
 suggest better ways of caring for people
 suggest practical approach to nursing care

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 make sense of what nurses do
 help those who work with them to understand fully what they do and why they do
that.

Components of Models
Nursing models have a number of components which address the aspect of patient
care. These are:
 The nature of people
 Causes of problems requiring nursing intervention
 Nature of the assessment process
 Nature of planning and goal setting
 Focus of intervention during implementation
 Process of evaluation and effect of care
 The role of the nurse

Let us now discuss some of the common nursing models that you will apply during
provision of nursing services. The three common nursing models are the:

1. Orem’s model
2. Henderson’s Nursing Model (activity of daily living)
3. Roper, Logan and Tierney Nursing Model (Activities of Living Model).

Let’s look at each in turn below.

1. Orem’s Model
The model was developed by an American nurse theorist by the name of Dorothea
Orem. Orem was searching for the meaning of nursing. In her search for the
meaning of nursing , she ended up developing the self-care deficit theory in 1970.
Her Model is also called the Self-Care Model. The goal of Orem’s theory is to help
the client perform self-care. According to Orem, nursing care is only necessary when
the patient is unable to fulfil biological, psychological, developmental or social needs.
The nurse therefore must determine why the client is unable to meet these needs,
what must be done to enable the client meet them, and how much self-care the client

9
is able to perform. The goal of nursing is to increase the client’s ability to
independently meet these needs (Orem, 2000).

Orem’s search for the meaning of nursing centred around 3 questions:

 What do nurses do and what should nurses do as practitioners of nursing?

 Why do nurses do what they do?
 What results from what nurses do as practitioners of nursing?
She later came up with a statement on which she based her model. The statement
says that: ‘Nursing has its special concern of a man’s need for self-care action and
the provision and management of it on a continuous basis in order to sustain life and
health, recover from disease or injury and cope with their effects’ (Orem, 1971).
Further, she t later came up with the following assumptions:

 People should be self-reliant and responsible for their own care and others in
their family needing care.
 People are distinct individuals in other words; no two people are the same.
 Nursing is a form of action or interaction between two or more persons.
 Successfully meeting universal and development self-care requisites is an
important component of primary care prevention and ill health.
 A person’s knowledge of potential health problems is necessary for promoting
self-care behaviours.
 Self-care and dependent care are behaviours learned within a socio-cultural
context.

Orem’s general theory of nursing had three parts. These are:

1. Theory of self-care deficit
2. Theory of self-care
3. Theory of nursing system

Let’s further look at each part in the following section.

1. Theory of Self-Care Deficit

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This theory states that self-care deficit (deficiency) results when the ability to perform
self-care is not adequate to meet the demands of the individual. Therefore people
will benefit from nursing because they have limitations in providing self-care related
to health issues. This theory can be summarised as follows:
 It specifies when nursing is needed.
 Nursing is required when an adult (or in the case of a dependent, the parent)
is incapable or limited in the provision of continuous effective self-care.

Orem identifies 5 methods of helping and these are:

 Acting for and doing for others
 Guiding others
 Supporting others providing an environment promoting personal development
in relation to meet future demands
 Teaching another

2. Theory of Self Care

This theory is based upon the idea that self-care is a learned behaviour that
individuals initiate and perform on their own behalf to maintain life, health and well-
being. Adults care for themselves, whereas infants, the aged, the ill and the disabled
require assistance with self-care activities. Self-care contributes to the self-esteem
and self-image of a person and is directly affected by the self-concept. This theory
can be summarised as follows:

 Self-care: this means the practice of activities that individuals initiate and perform
on their own behalf in maintaining life, health and well -being.
 Self-care agency: this is a human ability or ‘the ability for engaging in self-care’,
conditioned by age, developmental state, life experience, socio-cultural
orientation, health and available resources.
 Therapeutic self-care demand: refers to ‘totality of self-care actions to be
performed for some duration in order to meet self-care requisites by using valid
methods and related sets of operations and actions’.
 Self-care requisites: these are action directed towards provision of self-care.
Three categories of self-care requisites (requirements) are:
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 - Universal self-care requisites
- Developmental self-care requisites
- Health deviation self-care requisites

3. Theory of Nursing System

This theory suggests that a nursing system forms the basis on which nurses
prescribe, design, and provide nursing care. Nursing helps people to meet self-care
needs by using one of the three nursing systems namely:

 Totally compensatory nursing

In this system, the nurse will actually be the one to carry out the activities to meet
the self-care demands of an individual who is unable to do so, for example, an
unconscious patient who totally depends on the nurse.

 Partially compensatory nursing system

The nurse and the patient share the responsibility for the care in that the patient
is able to meet some of his or her own self-care demands.

 Educative/ supportive nursing system

The client has the primary responsibility for meeting the self-care demands. The
nurse only has to teach and support the client so that s/he is better able to meet
the demands himself.

Emphasis of the Self-Care Model

Orem’s self-care model emphasizes the existence of biological, physiological and
social systems within a person. The model also lays emphasis on activities that
maintain life, health and wellbeing. It also values personal responsibility for health.
Self-care is a universal requirement for sustaining and enhancing life and health.

Key components of Self-Care

Orem identified the following components of self-care concept:

i. The Nature of People

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The self-care model revolves around the fundamental belief that a need for self-care
always exists, and that ideally one has the right and ability to meet this need. Orem
refers to the self-care needs as ‘universal self-care needs’. There are eight of
universal self-care needs, namely:

 Maintenance of sufficient intake of air

 Maintenance of sufficient intake of water
 Maintenance of sufficient intake of food
 Provision of satisfactory elimination and excrement care (going to the toilet)
 Balance between activities and rest
 Balance between solitude (being alone) and social interaction
 Prevention of hazards to human life, human functioning and well being
 Maintain normalcy in the promotion of human functioning and development within
social groups, in accordance with human potential and known human limitation.

ii. Causes of problems requiring nursing intervention

According to Orem, an individual requires nursing care when a health experience
arises that creates a self-care need. The nurse should therefore conduct an
assessment to determine what needs the client has.

Iii. Nature of The Assessment Process

The aim of assessment is to establish the person’s self-care needs and to identify
whether a self-care need exists. According to Orem, the nurse needs to assess:

 if the client’s state allows self-care

 the demands being made on an individual for self-care
 the individual’s ability to meet these demands
 the reason for the health care deficit
 the client’s potential for re-establishing self-care in the future

According to Orem, assessment is continuous.

iv. Planning and goal setting process

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The nurse and the client establish goals that are realistic and that aim to reduce self-
care demands to the level that the client can meet. The goal should describe
observable behaviour to allow for evaluation at a later stage.

v. Focus of intervention during implementation

Implementing the care plan should involve the client, the nurse and significant others
(relations and friends). This means that nurses should not ignore the patient and
those who are close to the patient in developing the nursing plan.

vi. Evaluating the effects and quality of care

Evaluation is both summative and formative. It is based on the set goals. At the end
of implementing the nursing care plan, you must see whether the plan you had put in
place has met the set goals or objectives. For example, if the objective was to
reduce temperature. At the end of the intervention, the temperature should have
gone down.

vii. Role of the Nurse

Nurses assist clients to achieve competence in self-care. The nurse’s major role is
largely complementary. In cases where the patient is helpless, the nurse can provide
care for the patient in every aspect.

The following case study and problem analysis helps you to understand how to apply
Orem’s theory.

CASE STUDY 1

APPLICATION OF OREM’S MODEL

Mr Osward Nsama a 35 year old patient is admitted to the hospital

with a provisional diagnosis of Congestive Cardiac Failure. During
history taking the patient complained of dyspnoea, activity
intolerance, fatigue and generalised oedema. Using the Orem’s
nursing model, do a problem analysis on Mr Nsama and identify two
problems that you are going to nurse using the nursing care plan.

PROBLEM ANALYSIS

1. Sufficient intake of air

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 - Dyspnoea due to accumulation of fluids in the lungs
- Inability to sleep due to nocturnal Dyspnoea

2. Sufficient intake of water

- Oedema and weight gain due to accumulation of fluids in the

tissues.

3. Sufficient intake of food

- Patient had anorexia due to disease process

4. Satisfactory elimination function

- Risk of constipation due to reduced activity

5. Time spent alone balance with time spent with others

- Loneliness due to admission and non-visitation

6. Prevention of danger to self

- Risk of injury due to fatigue caused by reduced tissue

oxygenation

2. Maintain normalcy
- Restlessness due to shortness of breath and anxiety
- Anxiety due to knowledge deficit.

Please note that we are going to discuss how we can identify problems and develop
a nursing care plan later in this unit.

We hope that you have learned a lot of new ideas from Orem’s model. As we seek to
assist clients, we must ensure that we do not create dependence in the person we
are assisting. We must endeavour to ensure that clients work towards
independence.

The next model was developed by Virginia Henderson.

2.Henderson’s Nursing Model (activity of daily living)

This model was developed by Virginia Henderson. It emphasizes the existence of
biological needs within people. It further states that people have psychological and
social needs that can sometimes lead to the need for nursing care. She believed that

15
nurses must pay particular attention to accurately interpret both verbal and non-
verbal information from patients

Early in her career, Henderson realized two features of nursing. These are:

i. Nursing was different from medicine

ii. A clear definition of nursing was needed, hence by 1960 she came up with the
definition of nursing. She defined nursing as follows:

“It is the assistance given to an individual sick or well in the performance of those
activities contributing to health or to a peaceful death that he/she would perform
unaided if he had the necessary strength, will or knowledge”.

Henderson’s model of nursing looked at the following:

i. The Nature of People

According to Henderson, human beings whether sick or well have needs for food,
shelter, clothing, love and appraisal, sense of usefulness and mutual dependence on
social relationships. She elaborates this by identifying 14 fundamental needs
common to all human beings. These are to:
 breath normally
 drink and eat adequately
 eliminate body wastes
 move and maintain desirable posture
 sleep and rest
 select suitable clothes
 maintain body temperature within the normal range
 keep the body clean and well groomed
 avoid changes within the environment and injuring others
 communicate with others
 worship according to one’s faith
 work in such a way that there is a sense of accomplishment
 play or participate in the form of recreation
 learn, discover and satisfy curiosity

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 ii. Causes of Problems Requiring Nursing Intervention
According to Henderson, nursing care is needed whenever a person is unable
to carry out activities contributing to their health, their recovery or to a
peaceful death.

iii. Nature of Assessment

Henderson argued that the assessment of patients’ needs should involve
negotiation between the patient and the nurse except when the patient is in
coma. Then the nurse can decide what is good for the patient’s health.

iv. Nature of Planning and Goal Setting

Henderson advocates that long term goals should be set to help the patient
regain independence with respect to fundamental human needs. She also
advocated for setting short term or intermediate goals which should relate to
the problems identified during assessment.

v. Focus of Intervention During Implementation of Nursing Care Plan

Nursing intervention taken in the form of nursing activities should aim at
achieving long term, intermediate and short term goals which have been set.
These goals should relate to the human needs. She pointed out that nursing
care should be carried out by professionals and that the plan of care should
include drugs and treatment prescribed by the physician. She also advocates
that a successful nursing intervention requires involvement of the patient,
relatives and members of the health care team.

vi. Process of Evaluation of The Quality and of Effects of The Health Care
Plan
Evaluation is aimed at looking at the extent to which the patient has been
helped by the nurse to meet basic needs. It also inquires to what extent the
agreed upon objectives have been met.

vii. Role of the Nurse

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 She stressed the unique functions of the nurse as an independent health care
professional. She emphasized the complementary role that the nurse plays in
seeking to substitute for what the patient lacks and make them complete,
whole and independent. She sees also the role of the nurse as that of a
physician’s helper with the possibility of nursing goals being brought under
medical plan of treatment.

As you can see, the two models (Orem’s and Henderson’s) have some elements in
common. In both of them, the role of the nurse only goes as far as complementing
what the patient is able to do.

Next, we shall look at Roper, Logan and Tierney Nursing model.

3. Roper, Logan and Tierney Nursing Model (Activities of Living Model)

This model was developed by Nancy Roper, Winfred W Logan and Alison J. Tierney.
The model focuses on everyday activities that people carry out. If any of these
activities are neglected, an individual is likely to suffer ill health. The model shows
relationships between various components of the model.

Component of the Model

There are five main components of this model, namely:
a) Activities of Living (AL)
b) Life span
c) Dependence / Independence continuum
d) Factors Influencing activities of living
e) Individuality in living

Let’s look at each activity in further detail.

a. Activities of Living
The activities of living include the following:

 Maintaining a safe environment

 Communicating

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  Breathing
 Eating and drinking
 Eliminating
 Personal cleansing and dressing
 Controlling body temperature
 Mobilizing
 Working and playing
 Expressing sexuality
 Sleeping
 Dying

Maintaining a Safe Environment

Many of the everyday activities are aimed at keeping a safe environment, for
example, a home environment is kept safe by keeping poisonous substances and
dangerous articles in safe places, unplugging electrical appliances at night, and
guarding against fire. The aim of personal and domestic cleanliness is to decrease
the number of microorganisms in the environment thus rendering it safer.

Communicating
The activity of communicating includes the use of verbal and non-verbal language.
Communication helps to transmit feelings such as pleasure and displeasure.
Communication permeates the whole area of interpersonal interaction and human
relationships which are an important dimension of human life.

Breathing
The very first activity of a new born is breathing and the ability to do so is vital.
Through this activity, oxygen is taken in and carbon dioxide taken out. Oxygen is
necessary for human life. When the brain cells are deprived of oxygen, irreversible
damage is likely to occur. All other activities of living are entirely dependent on
breathing.

Eating and Drinking

These activities are necessary to sustain life. Eating is necessary for nourishment.
The way meals are taken and selected reflect the influence of socio-economic

19
factors on this activity of living. Many people in the world today die from starvation
and malnutrition. This serves as a reminder of the essential nature of this activity of
living.

Eliminating
This is closely associated with the activity of living of eating and drinking. The activity
of elimination is necessary for health living. It helps to get rid of waste products.
Elimination is regarded as a highly private activity and assistance of clients to
achieve this activity when hospitalized is very important to prevent constipation. To
the bed ridden, bed pans should be provided.

Personal Cleansing and Dressing

Personal cleansing and dressing is necessary for health living. The activities of living
(AL) help in the prevention of diseases such as scabies, hypothermia and
pneumonia among others. Personal cleansing promotes a sense of wellbeing, self-
esteem, comfort, relieves fatigue, and improves blood circulation. It includes
activities like bathing, oral care, and nail care. Personal dressing offers protection to
the body, and is done according to the culture and weather.

Controlling Body Temperature

The temperature of the human body is maintained within a narrow range that is
normal. This is necessary for many of the body’s biological processes and it ensures
personal comfort, regardless of the environmental temperature. Human cells cannot
survive very long when subjected to extremes of heat and cold. Over exposure to
heat may lead to heat stroke, while coldness may lead to hypothermia. Therefore,
this activity is also linked to personal dressing, as people dress according to the
weather to maintain normal body temperature.

Mobilising
This refers to the movements produced by the group of muscles that enable people
to sit, stand, walk and run. It also applies to smaller movements such as those of the
feet. These movements are necessary to achieve good health. This activity is linked
to activities of living such as, work and play, breathing and eating and drinking.

20
Mobilization helps to improve muscle tone, prevent contracture and promote blood
circulation. Immobility may lead to muscle atrophy due to disuse and contractures.
This can be prevented by doing passive and active exercises for bed ridden patients.

Working and Playing

Working provides income from which essential costs and leisure activities are met.
Playing provides some form of activities. These are necessary for personal
satisfaction and for a healthy mind. Playing helps in relieving stress and tension, and
promotes blood circulation thereby preventing diseases associated with immobility
such as deep vein thrombosis.

Expressing Sexuality
This activity of living is not only confined to sexual intercourse though it is an
important dimension of adult relationships. It is essential for the propagation of
human species. There are many more ways in which sexuality is expressed.
Femininity and masculinity are reflected in physical appearance, strength, odour and
clothes.

Sleeping
Sleeping allows people to rest. Lack of sleep can lead to ill health. Adults spend one
third of their lives sleeping. Sleep helps in growth and repair of worn out tissues,
promotes relaxation and helps people to cope with stresses of daily living. Lack of
sleep may lead to discomfort, poor memory and lack of concentration. Therefore, a
conducive environment should be created to promote sleep.

Dying
Man is mortal. The process of living is a fatal one and the final act of living is dying.
Grieving is the activity linked with dying through which a bereaved person comes to
term with the death of a loved one. Helping the family to cope with the loss and
preventing depression is very important. There is need to explore views and feelings
on dying from the patient and family. Spiritual support is necessary to provide hope
on life after death for believers. If not handled properly this activity may lead to
depression and suicidal attempts.

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Let’s now look at the second component of this model.

b. Life Span
Living is concerned with the whole person’s life and each person has a life span
which extends from birth to death. People go through continuous changes during
their life span. These changes are influenced by: socio-cultural factors, biological,
psychological, environmental and political-economic circumstances encountered
throughout life. For example, there is a statutory age for entering.

The third component is dependence and independence continuum which is

describes the movement of individuals from being dependent on the provider to an
independent role at different stages of life.

c) Dependence / Independence Continuum

This model is closely linked to other activities of living and life span. Each person has
an independence / dependence continuum for each activity of living, because there
are stages in life when a person cannot perform certain activities independently. As
indicated by Figure 1 below, the movement from dependence to independence can
take either direction of the continuum.

Total dependence Total independence

Figure 1: The dependence/independence continum

Independence is the ability to perform activities of living without help, for example,
cleansing and dressing. Dependence is when you depend on others for help with
most of the activities of living, for example, new born babies. Children gradually
move from a state of total dependence along the continuum towards the independent
continuum pole for each activity. Adult dependence occurs as a result of illness,
accidents or old age, for example, use of wheel chair for mobility. Also healthy
people are dependent on farmers for eating and drinking. Therefore there is no state
of absolute independence in the activities of living.

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The dependence / independence continuum is also closely associated with the
factors that influence the activities of living. Let’s look at these factors in the next
component.

d) Factors influencing activities of living

The following factors influence activities of living:
 Biological:
Relates to the human body’s anatomical and physiological performance and is
partly determined by an individual’s genetic inheritance, for example, facial
appearance, stature or physique.

 Psychological:
This factor influences living throughout the lifespan especially intellectual and
emotional development and has a bearing on a person’s level of independence.
Psychological factors can lead to intellectual impairment and stress, among
others.

 Socio-Cultural:
These include spiritual, religious and ethnic aspects of living. Socio-cultural
factors have a bearing on a person’s level of independence by influencing the
person’s individuality. They also affect the way each person carries out activities
of living, for example, the role of an individual in society or status in the
community. These factors are closely related to biological, psychological,
environmental, and politico-economic factors.

 Environmental:
They influence living throughout lifespan and have a bearing on the person’s
level of independence. Inevitably they influence the person’s individuality in living
and affect the way each person carries out activities of living, for example,
atmospheric pollutants like dust should be minimized to prevent respiratory
infections in a home or hospital.

 Politico-Economic:

23
 These have legal connections and action is reflected in legislation. They influence
living throughout lifespan and have a bearing on the person’s level of
independence. They influence individuality in living and affect the way each
person carries out activities of living, for example, poverty determine people’s
health, while political laws determine economic development. This factor is
related to environmental, socio-cultural, psychological and biological factors.

The final component is individuality in living.

 Individuality in living:
The model focuses on living as it is experienced by each person’s while carrying
out activities of living. For example, how a person carries out activities of living,
how often, where, why, what the person knows about activities of living, beliefs
and the attitude towards the activity of living. Individuality in living is achieved by
use of a nursing process which involves: assessment, diagnosis, planning,
implementation, and evaluation. The nurse’s role is seen as that of an
independent practitioner as well as playing the dependent role.
Let us now look at another case study to help you understand how this model is
applied in the nursing process.

CASE STUDY 2

APPLICATION OF THE ROPER, LOGAN AND TIERNEY MODEL

Inonge a 14 year old girl is admitted in your ward with a sickle cell
crisis and is complaining of severe joint pains and headache. Using
the Roper, Logan and Tierney model do a problem analysis and
identify 3 problems that you will nurse using a nursing care plan.

PROBLEM ANALYSIS USING THE ACTIVITIES OF DAILY LIVING

MODEL

Maintaining a safe environment

For you to maintain a safe environment you need to do the following;
- Prevent the risk of falls related to weakness and dizziness.
- Need to prevent infection and prompt treatment.
- Need to be nursed in isolation.
- Restlessness may lead to falls.
Communication
The following can affect effective communication during the care of
the client:

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 - Severe pain may impair cognitive perception which may affect
the listening, speaking and attention.
- Anxiety and lack of usual contacts may affect communication.
- Crying due to pain may affect communication.

Breathing
The following are the causes of breathing problems presented by
Inonge:
- Inonge has shortness of breath at rest or with activity.
- Inonge has rapid respirations and pulse rate due to anxiety
and pain.
Eating and drinking
The problems identified below are related to eating and drinking:
- Poor appetite related to nausea and vomiting.
- Altered nutrition less than body requirements related to nausea
and vomiting.
- Need for frequent mouth wash to improve appetite.
- Need to take a lot of fluid/water in order to remain hydrated; this
help to keep the blood diluted which reduces the chance that the
sickle cells will form.
Elimination
The following are the problems identified related to elimination:
- High risk of developing urinary tract infection related to low
immunity.
- Reduced urinary output related to plugging of the small blood
vessels which supply the kidneys.
Control of body temperature
Problems related to body temperature are as follows;
- Need to avoid extremes of temperature (exposure to extreme
heat or cold can trigger the formation of sickle cells).
- Need to monitor temperature four (4) hourly.
Personal cleaning and dressing
The following are the problems related to personal hygiene:
- Needs assisted baths and oral care.
- Need assistance to dress up due to pain.
Mobilizing
The following are the problems related to mobility:
- Limited mobilisation related to long bone pain. Pain may vary in
intensity and can last for a few hours to few weeks.
- Body weakness disturbs mobility.
- Inonge experiences unsteady gait thereby limiting mobility.
Working and playing
The following are the problems related to working and playing:
- Create time for playing, necessary to reduce stress and anxiety.
- Needs diversional therapy such as playing with a toy car.
- Unfamiliar hospital environment and lack of usual contacts may
affect working and playing.
- Confinement due to hospitalisation reduces time for playing.

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 Expressing sexuality
The following are the problem related to sexual expressing:
- Lack of privacy may lead to frustration.
Rest and sleeping
The following are the problems related to rest and sleeping:
- Severe pain may affect rest and sleep.
- Noise and nursing procedures may affect rest and sleep.
Dying
The following are the problem related to dying:
- Need to give adequate information to the parent especially the
mother about the condition.
- Need for spiritual support from their church elder or priest.

All the models that we have described above are applied and implemented using the
nursing process. Keep in mind the components of these models as we will discuss
how we can apply them using the nursing process.

1.5 The Nursing Process

The nursing process is a problem solving approach to nursing that involves
interaction with the client, making decisions and carrying out nursing actions based
on an assessment of individual patient situation.

It is a variation of scientific reasoning that allows nurses to organize and systematize

the nursing practice.

What is the nursing process?

The Nursing process is a systematic problem solving approach of giving

individualized nursing care (Cravern & Hirnle, 1992).

The nursing process is a tool that you need to understand well because it will assist
you to put your nursing knowledge into practice.

26
The nursing process is the common thread that unites different types of nurses who
work in various areas. It is the essential core of practice for the registered nurse to
deliver holistic, patient-focused care.

The nurse follows the nursing process to organize and deliver nursing care. The use
of the nursing process allows the nurse to integrate elements of critical thinking to
make judgments and take actions based on reason. The nursing process is used to
identify, diagnose and treat human responses to health and illness (American nurses
Association, 2003).

1.5.1 Components of the Nursing Process

The nursing process has 5 components. These are:

1. Assessment
2. Nursing diagnosis
3. Planning
4. Implementation
5. Evaluation

Let’s look at each component in detail below.

1. Assessment:
This refers to the systematic collection of subjective (what the patients feels and
says) and objective (what you observe) data with the goal of making clinical nursing
judgment about the patient or family. During assessment you have to consider the
physical, psychological, emotional, socio-cultural and spiritual factors that may affect
the health status of your client.

This stage is characterized by data collection, grouping of data into meaningful

categories, physical examinations, laboratory tests and observation skills.

Types of data
As we mentioned earlier, these are subjective and objective data.
 Subjective data: this is the information that is only obvious to the patient. It is also
known as covert data or symptoms, for example, pain.
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 Objective data: this is information that is detected by the observer, for example,
pallor. It is also known as overt data or signs.

Sources of data
The following are the sources of assessment data:
 Primary data: this information is obtained from the patient. It is gathered through
informal and formal interviews, and physical examinations.
 Secondary data: this information is obtained from the patient, patient’s family,
patient records, diagnostic tests, and reports.

2. Nursing Diagnosis
This is a combination of signs and symptoms that indicate an actual or potential
health problem that nurses are licensed to treat and are capable of treating.

Nursing diagnosis can be formulated in 2 ways, that is, for an actual problem or for
a potential problem.

 Actual problem: this is a problem that already exists. When the nurse interacts
with the patient it can be elicited because the patient is experiencing it. The
nursing diagnosis for an actual problem should have a problem, cause and
manifestation. For example, if you identify dyspnoea as a problem in a patient
with Pulmonary Tuberculosis, the nursing diagnosis could be ‘Dyspnoea related
to reduced lung capacity evidenced by laboured breathing’.

 Potential or risk problem: this is a problem that is likely to occur due to the
condition of the patient if certain nursing measures are not observed. The
problem is not actually there, for example, the risk of developing pressure sores
is a potential problem for a patient who is unconscious. The nursing diagnosis for
a patient with a potential problem should have a problem and a cause. For
example, ‘susceptibility to develop pressure sores related to immobility.’

Data analysis leads to formulation of the nursing diagnosis. The nurse uses
elements of critical thinking and scientific methods to analyse data so that valid
conclusions about the patient are reached and accurate diagnoses are made.

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Table 1 below lists the approved international nursing diagnosis

Table 1: Selected Approved International Nursing Diagnoses (Source: Nanda, 2005- 2006)

1. Knowledge deficit related to ….

2. Impaired mobility related to…
3. Non compliance
4. Self-care deficit related to bathing/dressing/grooming/feeding/toileting
5. Ineffective airway clearance
6. Anxiety
7. Risk for aspiration
8. Bowel incontinence
9. Ineffective breastfeeding
10. Ineffective breathing patterns
11. Decreased cardiac output
12. Impaired verbal communication
13. Constipation
14. Ineffective coping
15. Delayed development
16. Failure to thrive
17. Ineffective feeding patterns
18. Fluid volume deficit
19. Fluid volume excess
20. Impaired gas exchanged
21. Unstable glucose levels
22. Dysfunctional grieving
23. Hyperthermia
24. Hypothermia
25. Disturbed personal identity
26. Urinary incontinence
27. Risk for infection
28. Risk for injury
29. Sedentary life style
30. Nutritional deficit less than body requirement
31. Acute pain related to
32. Chronic pain related to
33. Distorted self-concept
34. Impaired skin integrity
35. Risk for impaired skin integrity
36. Disturbed sensory perception
37. Sleep deprivation
38. Impaired social interaction
39. Risk for suicide
40. Delayed surgical recovery
41. Impaired swallowing
42. Ineffective therapeutic regimen management
43. Ineffective thermoregulation
44. Disturbed thought processes
45. Impaired tissue integrity
46. Urinary retention

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3. Planning
Before you continue reading, complete the following activity.

ACTIVITY 1.1
Write down in your notebook the meaning of planning.

Well done! Now compare your answer with what you read in the following section.

Planning is creating an organized course of action, that is designed to change

negative health response to a more positive one. The nurse, patient and family must
participate actively in this stage to set goals.

The stage involves four (4) main activities:

 Setting priorities from among identified potential and actual problems.
 Setting objectives that must be Specific, Measurable, Achievable, and Realistic
and Time bound (SMART).
 Select appropriate nursing interventions that should be done with scientific
reasoning.
 Writing of the care plan.

4. Implementation
This is the step that involves action or doing, and the actual carrying out of nursing
interventions outlined in the nursing care plan. This phase requires nursing
interventions such as applying a cardiac monitor or oxygen, direct or indirect care,
administration of medication, etc. It involves therapeutic interaction between the
nurse and the client. This requires technical competence and proper manual
dexterity. The nursing actions focus on resolving, dissolving or diminishing the
patient’s functional health status problem.

5. Evaluation:
This is the process of determining to what extent the established goals have been
attained. Evaluation involves analysing the outcome of the nursing action to see if

30
the care given is effective. Observations are important in this stage and are widely
used. Updating of the care plan is done in this stage. The outcome should be
compared with the objective. Evaluation is an on-going and continuous process
performed throughout the nursing process. It may be formative (done continuously or
on going through out the program) or summative (done at the end of the program).

The nursing process has multiple advantages to the nurse, client and community at
large. However, the process also possesses some disadvantages which are
described below.

Advantages of the nursing process to the client

 It is adaptable to every patient
 It contributes to individualized care.
 It contributes to high quality care.
 Client feels part of the care team.
 It helps the client to co-operate and become involved in his/her care.
 It responds to the continually changing needs of a client.

Disadvantages of the nursing process to the client

 It may lead to frustration especially when the patient’s need is not given the
first priority
 It subjects the patient to a lot of talking and thinking thereby disturbing rest
and sleep.

Advantages of the nursing process to the Nurse

 It can be used in any situation in which a nurse gives care.

 It provides for constant evaluation
 It is a basis for improving care
 It is a logical, organized way of approaching a nursing care problem
 It allows for great creativity or innovation
 It is oriented to obtaining objectives.
 It helps to make wise decisions

31
  It prevents duplication of work
 It helps the nurse to diagnose and treat human response to actual or potential
health Problems.
 It helps the nurse to help clients meet agreed upon outcomes.
 It provides a common language and process for nurses to think through
client’s clinical problems.
 It provides an organized structure and frame work for the delivery of nursing
care.
 It helps to evaluate the problems of the client.
 It acts as a tool for providing excellent care to the client.
 A good care plan can serve time, energy and frustrations that is generated by
client and staff.
 The nurse can feel a real sense of accomplishment and professional pride
when goals in a care plan are met.
 If the plan fails, the nurse can explore reasons for the undesirable result.
 It creates a good relationship between clients and the nurse
 It provides the nurse room for critical thinking.
 Allows the nurse to organize and systematize the nursing practice.
 Encourages the nurse to have confidence about specific problems the client is
experiencing and goals to be taken upon those problems.

Disadvantages of the nursing process to the Nurse

 It requires a lot of stationary

 It is time consuming
 It is difficult to implement due to shortage of manpower
 It requires use of observation skills such as cues on non-verbal
communication

Advantages of the nursing process to the Community

 Participation of the relatives in the care of the patient helps the patient feel
loved and supported.

32
  It helps the community participate in the care of the patient or the health care
system.
 The community is able to evaluate care provided to the client and try to
improve on it.
 The community is able to participate in identifying the problem in their
community.

Disadvantages of the nursing process to the Community

 As the community is involved, the nursing process is no longer client centred,

because family members may put their own needs, fears in the nursing
process, thus dictating the plan of care.
 The family members participating in the care of patient may lack the required
skill, knowledge and resources needed to offer comprehensive care to the
client.

CHECKPOINT QUESTION NO 2

1. Define nursing process.

2. Can you list the main three nursing models that we have discussed?
3. Without referring to the notes: Fill in the boxes what constitutes each stage of the nursing
process:

Assessing Diagnosis Planning

Assessment PlP
Diagnosis Planning

Evaluation Implementing

Answers
1. The nursing process is a problem solving approach to nursing that involves interaction with
the client, making decisions and carrying out nursing actions based on an assessment of
individual patient situation
2. Orem’s model , Henderson model and Nancy, Roper and Logan model
3. Assessment: Gather information about the client (both subject and objective)
Diagnosis: Identify the client’s problem
Planning: Set goals of care and desired outcomes and identify appropriate nursing action

33
 Implementation: Perform the nursing actions identified in planning
Evaluation: Determine if goals met and outcomes achieved

1.6 Nursing Care Plan

This is part of the third step in the nursing process, where the nurse formulates a
plan, implements and evaluates the nursing care provided. The following are the five
(5) components of the nursing care plan:

1. Problem Identified: this describes the client’s health problem or response to the
nursing therapy being given. This is to direct the formation of client goals and
desired outcomes. It uses qualifiers or descriptive terms that can be used to give
additional meaning to the statement. For example, deficient, impaired, decreased,
ineffective.

2. Nursing Diagnosis: this is a clinical judgment about individual, family, or

community responses to actual or potential health problems/life processes. It
provides the basis for selection of nursing interventions to achieve outcomes for
which the nurse is accountable.

3. Objectives: these are specific and measurable statements designed to reflect the
patient highest level of wellness and independence in function achieved from nursing
care. These can either be short term or long term. Objectives should be accurate,
feasible and time bound.

4. Implementation: nursing interventions are treatments based upon clinical

judgment and knowledge that a nurse performs to enhance patient / client outcomes.
Nursing interventions must be specifically designed to meet the identified goal and
should be supported by a scientific rationale.

5. Evaluation: this is the judgment of the effectiveness of nursing care to meet

client goals based on the client’s behavioural responses.

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Let us now reflect on what you have learnt so far. Using the case study that was
given under the Orem’s model, the following problems can be identified:
 Dyspnoea
 Oedema
 Activity intolerance
 Anxiety

We will use these problems to formulate a nursing plan as illustrated in Table 2.

35
 Table 2: Nursing Care Plan (I)

Date Time Problem Nursing diagnosis Objective Nursing intervention Evaluation

Dyspnoea Dyspnoea due to impaired To relieve - To advise patient to be sitting in upright position - Dyspnoea relieved after 1
gas exchange related to Dyspnoea supported by pillows or back rest to promote lung hour of nursing intervention
interstitial and alveoli within 30 expansion. as evidenced by patient’s
oedema evidenced by minutes to 1 - To administer oxygen to patient whenever normal breathing pattern of
shortness of breath hour of necessary that is, 5 litres per minute to perfuse body 18- 20 breaths/minute.
admission. tissues.
Oedema - Oedema due to excess To relieve - Patient advised to elevate the legs in order to - By the end of one week, of
fluid volume related to Oedema by the promote venous return treatment and before
compensatory regulatory end of one - Patient advised to restrict salt intake in the diet discharge, oedema of the
mechanisms secondary to week and because salt contains sodium, which retains fluids. face and feet subsides.
decreased cardiac output throughout - To give prescribed Lasix to the patient to
and poor venous return hospitalization. encourage fluid excretion.
evidenced by swollen feet - To monitor oedema by daily weighing to check if
and face. subsiding or not.
Activity - Activity intolerance To promote - Advise patient to avoid strenuous activities which At the end of one week of
intolerance related to weakness, patient can easily tire him/her hospitalization, patient
fatigue and general tolerance to - Doing all nursing procedures collectively to avoid verbalizes tolerance of an
malaise evidenced by activity by the tiring the patient. activity at safe and
patient verbalization and end of one - Assist the patient with activities of living for example acceptable levels.
irregular respirations week of bathing, grooming, eating and so on - Respirations of less or
hospitalization. - Encourage the patient to eat, especially energy equal to 20 breaths/ minute
foods which give energy. noted after an activity.
Anxiety - Anxiety related to To relieve - Explain the disease process to the patient so that At the end of 4 days patient
dyspnoea, oedema, anxiety within 4 patient is knowledgeable of the course of the illness. verbalized relief of anxiety
perceived threat of death days and - Patient advised to be in upright position to relieve and no longer expressed
evidenced by patient throughout dyspnoea. anxious facial expressions.
verbalization and facial hospitalization. - Encourage open discussions of feelings about
expressions diagnosis to demonstrate acceptance and concern
for patient and allow verbalization of concern.

36
 As you can see, using the nursing process we are able to provide care that is based on the individual needs of the clients in order
to achieve the desired outcomes. Let us go further and see how we can utilise the case study under the Roper, Logan and Tierney
Model to identify problems and devise a nursing care plan. Some of the problems identified were: joint pains, risk of injury and
anxiety.

Table 3: Nursing care plan (II)

Problem Nursing Diagnosis Goal Implementation Evaluation

Joint Pains Joint pains related to The patient will ● Allow Inonge to assume the most comfortable Joint pains have been relieved
blockage of blood flow have joint pains position. within 1 hour of hospitalization
through blood vessels to relieved within 1 ● Encourage the patient to take a lot of fluids to promote evidenced by verbalization and
the joints by sickle hour of adequate hydration for easy blood flow. the patient able to sleep
shaped red blood hospitalization ● Offer diversional therapy to Inonge so as to keep her comfortably.
vessels evidenced by mind off the pain
frowning and
verbalization of pain. ● Give prescribed analgesic to alleviate pain.
Risk of injury Risk of injury related to To prevent injury ● Inonge is in a railed bed to prevent falls Injury prevented throughout
restlessness due to joint throughout ● The rails of the bed will be padded to prevent injury hospitalization evidenced by
pains hospitalization when the patient hints the rails. patient being free from injury
● Offer a bed pan to the patient so that they don’t walk during hospitalization.
to the toilet as they may fall.
Anxiety Anxiety related to The patient will ● Explain in simple terms the hospital environment to Anxiety relieved during the first
knowledge deficit have anxiety Inonge and orient her to the ward environment, staff 48 hours of hospitalization
regarding the condition relieved within and other kids in the ward. evidenced by patient not asking
and unfamiliar ward 48 hours of ● As part of diversional therapy, her favourite toys were any more questions and being
routine and environment hospitalization. brought for him from home, so that she does not miss less irritable.
evidenced by asking home so much.
repeated questions and ● The disease process was explained to the patient so
irritability. as to increase knowledge base regarding the

37
condition

38
 CASE STUDY 3

Mr Mutale is admitted to the male medical ward with Pulmonary Tuberculosis. He has a wound on his right leg and has difficulties in
breathing (dyspnoea). Identify two problems and plan his care using the nursing care plan

Table 4: Example of a nursing care plan (III)

Date Time Problem Nursing Diagnosis Goal Implementation Evaluation

24th July 18 00 Dyspnoea Dyspnoea due to To relieve dyspnoea -Position Mr Mutale in a semi fowler’s Dyspnoea relieved within 1 hour
hours impaired gaseous within 1 hour of position using a backrest to promote of hospitalization evidenced by
exchange in the admission and lung expansion and allow more air entry normal respiratory rate of 22
alveoli related to throughout on inspiration. breaths per minute.
the inflammatory hospitalisation. -Administer prescribed oxygen by mask
process evidenced with a flow of 4-8L/M. This is to provide
by increased concentrated oxygen and promote
respiratory rate of tissue perfusion.
34 breathes per -Administer prescribed analgesic that
minute. will help in reducing chest pains hence
allowing for deep breathing.

Risk of wound Risk of wound Patient will be free -Dress the wound daily using the Patient is free from infection
infection infection related to from infection prescribed antiseptic to promote wound throughout hospitalisation
poor wound throughout healing evidenced by absence of pus
hygiene hospitalisation -Use aseptic technique during wound and slough formation on the
dressing to prevent contaminating the wound.
wound
-Encourage Mr Mutale to eat a lot of
fruits and vegetable and meat products
in order to promote wound healing

39
We hope you now understand how to prepare a nursing care plan. Next, we shall
look at the interactive process, which looks at the relationship between the nurse and
the patient, as well as the nurse and the health care team.

1.7 Interactive Processes in Nursing Care

What is the process of interaction in nursing?

According to King (1981), ‘the process of interactions between two or more

individuals represents a sequence of verbal and non-verbal behaviours that are goal
directed’.
In the interactive process two individuals mutually identify goals and the means to
achieve them. The relationship between the nurse and the patient is referred to as a
therapeutic relationship, interpersonal relationship, or as a helping relationship. It is
an interactive process between the nurse and the patient. Communication is also
very important between the nurse and the patient as well as members of the health
care team. Let’s look at these two aspects of this relationship in the following
section.

1.7.1 Helping Clients

Helping is a growth- facilitating process in which one person assists another to

solve problems and to face crises in the direction the assisted person chooses. In
the nurse-patient relationship, the nurse is the helper while the patient/client is the
one receiving help.

The helping relationship has three sequential stages, each of which has identifiable
tasks and skills. These are:

1. Pre-interaction phase
2. Introductory / orientation phase
3. Working Phase

1
It is important to note that these stages must progress in succession as each stage
builds on the one before it. Let us look at each of these stages one by one.

1. Pre-interaction Phase
The pre-interactive phase is similar to the planning stage which is conducted before
an interview. Usually the nurse has information about the client before the meeting
with the client. Some of this information is the client’s name, age, sex, address and
medical / social history. The pre-interactive phase can create some anxiety in the
nurse but it is important for the nurse to recognize and accept these feelings so as to
contain them. It is also important for the nurse to identify the specific information to
be discussed in order to achieve positive outcomes from the interaction.

2. Introductory / orientation phase

This phase is very important as it sets the pace for all the other phases. The other
tasks in the introductory phase include getting to know each other and developing a
degree of trust. You should be aware that in the initial stage the client may display
some resistive and testing behaviours. Resistive behaviours are those that inhibit
involvement, cooperation, or change, for example, not answering questions or
refusing to contribute to the discussion. This can be due to fear of exposing and
facing ones feelings and weakness. The testing behaviours are aimed at examining
the nurses’ interest and sincerity in the discussion with the client.

This phase has three main stages, namely:

a) opening the relationship
b) clarifying the problem
c) structuring and formulating the contract.

Let’s now look each stage in turn below.

a) Opening the relationship

The following activities take place during this stage:
 Both the nurse and the client identify each other by name
 Both can initiate the relationship.
 When the nurse initiates the relationship it is important that the nurse explains
her/his role to the client so that they know what to expect.

2
 When the client initiates the relationship, the nurse needs to help the client
express concerns and reasons for seeking help. The nurse can ask vague open
ended questions like ‘what is on your mind?’ The nurse should help the client to
be at ease by having a relaxed attending attitude.

b) Clarifying the problem

The major task for the nurse during this stage is to help clarify the problem to the
client as the problem may not be so clear in the initial stage to the client. To do this
the nurse needs to listen attentively to what the client is saying. S/he should also
paraphrase the client’s words and clarify with the client so as to get the actual
meaning of what the client is saying.

Do not ask the patient too many questions.

c) Structuring and formulating the contract

During this stage the nurse and the client develop some degree of trust and they
agree on the following:
 the location, duration and frequency of meetings
 overall purpose of the relationship
 how confidential material will be handled
 tasks to be accomplished
 duration and indications for termination of the relationship.

Let’s move on to the third stage of a helping relationship.

3. Working Phase
In the working phase the nurse and the client begin to view each other as unique
individuals and begin to appreciate and care for each other. During the first stage of
the working phase, the intensity of interaction increases and feelings of anger,
shame or self-consciousness may be expressed. If the nurse is skilled in this stage
and the patient is willing to do self-exploration, the outcome is a better understanding
on the part of the client of behaviour and feelings.

The working phase has four successive stages. These include:

3
a) Responding and exploring:
The nurse helps the client to explore thoughts, feelings and actions. In addition to
having listening and attending skills the nurse has to show:

 Empathy: which is the ability to share another person’s feelings and emotions
as if they were yours. The nurse must respond in ways that indicate that s/he
is listening to what the client saying and understand show they feel.
 Respect: the nurse must show respect for the client and the willingness to be
available and desire to work with the client.
 Genuineness: personal statements can be helpful in solidifying the rapport
between the nurse and the client. However, the nurse needs to exercise
caution when making reference to his or herself.
 Concreteness: it is important for the nurse to help the patient to be specific
and not generalize issues.

b) Integrative understanding and dynamic self-understanding

In this second stage of the working phase the client achieves an objective
understanding of themselves and their world. This understanding enables them to
change and take action. The nurse needs to employ the following skill:

 Advanced- level empathy- this skill enables the nurse to respond in ways that
indicate an understanding not only of what has been said but also of what is
hinted at or implied nonverbally
 Self- disclosure- the nurse willing but discreetly shares personal experiences.
 Confrontation- this involves the nurse pointing out discrepancies between
thoughts, feelings and actions that inhibit the client’s self- understanding or
exploration of specific areas. This should be done empathetically and not
being judgmental.

c) Facilitating and taking action

During this stage, the nurse plans programs within the clients’ capabilities and
considers long and short-term goals. The client needs to learn to take risks. The
nurse needs to reinforce successes and help the client recognize failures

4
realistically. The nurse and the client both need to have decision marking and goal
setting skills.

d) Termination phase
The nurse and client accept feelings of loss. The client accepts the end of the
relationship without feelings of anxiety or dependence. The nurse needs to have
summarizing skills and the client should be able to handle problems independently.

1.7.2 Communicating with Clients and the Health Care Team Members

What is communication? Take a minute to think about its meaning and then
complete the following activity.

ACTIVITY 1.2

Write down in your notebook the meaning of the word ‘communication’

Well done! Now compare your definition with the one in the following section.

Communication is a process of sending and receiving verbal and non-verbal

messages.

It should now be clear that at the core of nursing are caring relationships which are
formed between the nurse and those affected by the nurse’s practice. These
relationships can only be established by means of communication.

All behaviour communicates and all communication influences

behaviour

Levels of Communication
The nursing profession offers nurses with an opportunity to communicate at different
levels. Some of the levels at which nurses communicate are as follows:

a) Intrapersonal communication
This form of communication occurs within an individual and is also known as self-
talk, self-verbalization and inner thought (Balzer Riley 2000).

5
A person’s thoughts influence perception, feelings, behaviour and self-concept. The
nurse should be aware of the nature and content of their thoughts and try to replace
negative, self-defeating thoughts with positive assertions which will help to improve
either the nurse’s or client’s self -esteem and health.

b) Interpersonal Communication
This is one on one interaction between the nurse and another person and often
occurs face to face. It is the most frequently used in nursing situations and lies at the
heart of nursing practice. It takes place within a social context and includes all the
symbols and cues used to give and receive meaning.

Meaningful interpersonal communication results in exchange of ideals, problem

solving, and expression of feelings, decision making, team building, personal growth
and goal accomplishment

c) Small- Group Communication

Small group communication is interaction that occurs when a small number of people
meet together. It is usually goal directed and requires understanding of group
dynamics. According to Hybels and Weaver (1998), small groups are most effective
when:
 they are a workable size
 have an appropriate meeting place
 have suitable seating arrangements
 are cohesiveness
 have committed team members.

In this type of communication it is important to listen to others and also have respect
for others as partners.

d) Public Communication
This involves communication with an audience. Public communication requires
adaptations in eye contact, gestures, voice projection and use of media materials to
communicate messages effectively. Nurses do have opportunities to speak with

6
groups of consumers about health related topics, lead classroom discussions as well
as present scholarly articles to colleagues at conferences.

Basic Elements of Communication

What are the basic elements of communication:

There are 6 basic elements of communication. These are as follows:

 Referent
 Sender
 Message
 Channel
 Receiver
 Feedback

Let’s look at each element in turn.

1. Referent
A referent is anything that motivates a person to communicate with another. In the
health care setting referents can be things like odours, sounds, time schedules,
objects, ideas and emotions. If you know the stimulus that initiated a communication,
you are able to develop and organize messages efficiently and also perceive the
meaning in the message better.

2. Sender
The sender is the originator of the message and s/he formulates, encodes and
transmits the information they want to communicate. The accuracy and impact of the
message will depend on the sender's communication skill

3. Message
The message is the content of the communication. It may be in the form of words,
pictures or signs. Messages are interpreted by those who receive them through
personal perception, which may or may not distort the meaning intended by the
sender. Nurses can send effective messages by expressing themselves clearly,

7
directly and in a manner familiar to the receiver. It is important to lookout for
nonverbal cues which suggests confusion or misunderstanding from the listener.

4. Channels of Communication
Channels are means of conveying and receiving messages through visual, auditory
and tactile senses between the sender and the receiver. The more channels the
sender uses to convey a message, the more clearly it is understood. For example,
when teaching about insulin self-injection, the nurse talks about it, then
demonstrates the technique, gives the client printed information, and encourages
hands-on practice with the vial and syringe. Nurses use verbal, nonverbal and
mediated (technological) communication.

5. Receiver
The receiver is the one who receives and decodes the message from the sender.
The receiver is responsible for attending to, translating and responding to the
sender’s message.

6. Feedback
It is the flow of information from receiver to the sender, that is, the reaction to the
message. Feedback indicates whether the message was understood or not. For
communication to be effective both the sender and receiver must be sensitive and
open to each other’s messages, clarify the message and modify behaviour
accordingly.

Forms of Communication
Messages are conveyed verbally and nonverbally, concretely and symbolically.
When communicating, people express themselves through, words, movements,
voice inflection, facial expression and use of pace. These elements can work in
harmony to enhance a message or conflict with one another to contradict and
confuse it.

 Verbal Communication
Verbal communication uses verbal or written words. When using verbal
communication the nurse should be conversant with the necessary techniques
needed to make verbal communication effective. These techniques include:

8
- Vocabulary: for communication to be effective both the sender and the receiver
must understand each other’s words and phrases. If there is a barrier in
language, an interpreter should then be used. Nurses should desist from using
medical jargon because it can lead to a breakdown in communication, as the lay
person is not familiar with medical terminologies.
- Denotative and Connotative Meaning: Denotation is the literal meaning of the
word, connotation is a feeling or indirect meaning, which is influenced by the
thoughts, feelings or ideas people have about the word.For example i.e
Denotation: blue (color blue) Connotation: blue (feeling sad) Nurses should
ensure that they carefully select words and use the real meaning of the word
(denotative meaning) to avoid misinterpretation, especially when explaining a
client’s medical condition or therapy.
- Pacing: nurses should speak slowly enough for the conversation to be
successful. An appropriate speed and pace of speech should be maintained
throughout.
- Intonation: the tone of voice affects a message’s meaning. Depending on
intonation a simple statement can express anger, indifference or concern. It is
necessary for the nurse to maintain a reasonable tone of voice to avoid sending
unintended messages.
- Timing and Relevance: timing is very important in communication. Even when the
message is clear, poor timing can prevent it from being effective. For example the
nurse should not start teaching when the patient is in pain.
- Clarity: effective communication is simple, brief and direct. Clarity is achieved by
speaking slowly, clearly and using examples to make explanations easier to
understand.
- Brevity: is achieved by using short sentences and words that express ideas
simply and directly. For example, asking questions such as ‘where is your pain?’
is much better than ‘I would like you to describe for me the location of your
discomfort.

 Non-verbal Communication
Non-verbal communication is also known as body language. Non-verbal
communication often tells more about what a person is feeling than what is said.

9
This is because non-verbal behaviour is controlled less consciously than verbal
behaviour and majority of communication is non-verbal. As a health care provider,
you will learn more from observing a patient's non-verbal cues than from listening to
a patient's verbal communication.

Nonverbal communication includes the following:

 Physical appearance: such as, grooming, and manner of dressing. These

factors help communicate ones physical well-being, personality, social status,
occupation, religion, culture, and self-concept. A nurse develop a general
impression of a client’s health and emotional status through appearance, and
similarly, clients develop a general impression of a nurse’s professionalism in the
same way.

 Facial expressions: facial expressions convey emotions such as fear, anger,

surprise, happiness and sadness. It is important though to note that some people
do not reflect their emotions on their faces. They are said to have a flat affect. An
inappropriate affect is a facial expression that does not match the content of a
verbal message, for example, smiling when describing a sad situation. These
expressions must be interpreted when communicating with a patient. The ability
to interpret facial expressions leads to a better understanding of your patient's
condition.

 Posture and Gait: this refers to the way one walks, stands or sit, which can
reflect emotions, attitudes, health status and self-concept. For example, an erect
posture and a quick, purposeful gait communicate a sense of well -being and
confidence.

 Eye Contact: the readiness to communicate can be signalled by eye contact.

Maintaining eye contact during a conversation shows respect and willingness to
listen. Lack of eye contact may indicate discomfort, lack of confidence in
communicating, anxiety or defensiveness. However, culture also plays a role on
ones perception of eye contact. Some cultures may avoid eye contact as a sign
of respect.
10
 Sounds: some sounds, such as, sighs, groans, and sobs communicate thoughts
and feelings. When combined with verbal communication, sounds can send clear
messages.

 Gestures: these help to emphasise clarify and punctuate spoken words. For
example, pointing to an area of pain can be more accurate than describing the
location of pain.

As the nurse you must explore further if a patient's non-verbal message does not
match with their verbal message.

Caregiver's Body Language

Smiling, leaning forward, eye gazing and touching are elements of body language
that the nurse can use to improve her relationship with the patient. You should be
aware that your body language communicates messages to your patients, and so
you should ensure that you are respectful and considerate in speech and movement.
Use your body language to communicate effectively with the patients and their
families.

Factors Influencing Communication

As a nurse, you should communicate purposefully and focus on results and
relationships with your clients and team members. The following are some of the
factors that influence communication:

 Perceptions
Our perceptions of others influence our own verbal and nonverbal behaviors
when we are around those others. We choose what to communicate to others,
how to interact with them, and what to present about ourselves based, at least
in part, on our impressions of those others
 Values

Values are influential in dictating the behaviour of a communicator

in interethnic settings. Rokeach (1979: 2) defines a value ‘as a type of

11
 belief that is centrally located within one’s total belief system’. Values tell
us of how we should behave.The practitioner's values will lead them to
communicate in certain ways, because values will determine which ways of
communicating are deemed more desirable than others.
 Socio-cultural background
Sociocultural factors influence people's feelings, values, beliefs, behaviors,
attitudes, and interactions. The chance of misunderstanding or
misinterpretation of messages is higher in organizations with people from
different cultural backgrounds. This is due to inability to relate and truly
understand someone with a different background. This leads to assumptions
and speculation which feed bigger problems in organizations if left
unresolved.
Examples include social classes, religious beliefs, wealth distribution,
language, business practices, social values, customer preferences, social
organization, and attitude towards work.
 Knowledge
Different knowledge levels between the sender and receiver also influence the
meaning of communication. If they have similar educational qualifications,
communication will be effective. This is often true because they have similar
perception, thinking, and understanding on things.

 Environment
Environmental connections can have both negative or positive or anyone
influence on interpersonal communication. Some of the barriers to effective
communication include time, noise, place, climate, poor lighting, long-distance
barriers and visual noise.
For example, a conversation outside on a road during a windy or a rainy day
faces obstacles in communication that might not be present in a living room.

 Space and territoriality

Territoriality is a term associated with nonverbal communication that refers to
how people use space to communicate ownership/occupancy of areas and
possessions (Beebe, Beebe & Redmond 2008, p. 209).

12
 An example of demonstrating territoriality might be the car size. Driving a
large truck like the Ford F350 might be communicating that a value of owning
a lot of space on the highway. However, driving a small car like the Smart,
then might be communicating no need to occupy so much space.

Importance of Good Communication Between Health Care Team Members

Written and verbal communication between health care team members is important
for the provision of quality client care. Generally, the health care team communicates
through discussions, reports and records.

Before you continue reading, complete the following activity.

ACTIVITY 1.3
Write down in your notebook the meaning of the following words:
a) Discussion
b) Report
c) Record

Very good! Now compare your answers with the definitions in the following
discussion.

A discussion is an informal oral consideration of a subject by two or more members

of the health team, often leading to a decision.

Reports are oral, written or audiotaped exchange of information between caregivers.

Reports include, change-of-shift reports, telephone reports, transfer reports, and
incident reports, (Potter-Perry, 2005).

A record is always written. It is a formal, legal documentation of a client’s progress

and treatment.

Accurate, complete communication serves several purposes. These include:

 helping to co-ordinate care given by several people

13
  preventing the client from having to repeat information to each health team
member
 promoting accuracy in the provision of care and reducing the possibility of
error
 helping health personnel make the best use of their time by avoiding
overlapping of activities.

Attitude Towards Other Team Members

Nurses function in roles that require interaction with multiple health care team
members. Many elements of the nurse-client relationship are also applied in these
collegial relationships, which focus on accomplishing the work and the goals of the
clinical setting. Communication in such relationships may be geared towards team
building, facilitating group processes, collaboration, consultation, delegation,
supervision, leadership, and management. A variety of communication skills are
needed, including presentational speaking, persuasion, group problem
solving, ,providing performance reviews and writing business reports. Both social
and therapeutic interactions are needed between the nurse and health care team
members in order to build morale and strengthen relationships within the work
setting. As a nurse, you need friendships in order to cope with many stressors
imposed by the nursing role. You must therefore build positive relationships with
colleagues and co-workers.

1.8 Documentation and Reporting

What is documentation?

Documentation is anything written or printed that is relied on as record or proof for

authorized persons (Potter-Perry, 2005).

1.8.1 Purpose of Documentation

A record is a valuable source of data that is used by all members of the health care
team. It is used for communication, legal documentation, financial billing, education,

14
research, auditing and monitoring. Let’s look at these uses further in the following
section.

 Communication
Through documentation, the health care team members communicate client’s
needs and progress, individual therapies, client education and discharge
planning. The plan of care needs to be clear to anyone reading the chart. A
client’s documentation should be the most current and accurate source of
information about a client’s health care status.

 Legal documentation
Accurate documentation is one of the best defences for legal claims associated
with nursing care. To limit nursing liability, nursing documentation should clearly
indicate that individualized, goal-directed nursing care was provided to a client
based on the nursing assessment. The documentation needs to describe exactly
what happened to a client. This is best achieved if the nurse charts immediately
after care is provided. Even if the nursing care was excellent, in a court of law,
‘care not documented is care not given’.

There are four common issues in malpractice that are caused by inadequate
documentation. These are:
- Not charting the correct time when events occurred
- Failing to record verbal orders or failing to have them signed
- Charting action in advance to save time
- Documenting incorrect data

 Financial Billing
Medical records are also audited to review financial charges used in the clients
care. Private insurance carriers and financial auditors review records to
determine the reimbursement that a client or a health care agency receives.
Accurate documentation of supplies and equipment assist in accurate and timely
reimbursement.

 Education

15
 The effective way to learn the nature of an illness and the individual client’s
response to it is to read the client’s care record. No two clients have identical
records’. From this information, students identify the patterns of various health
problems and can begin to anticipate the type of care required by a client.

 Research
A nurse may use clients’ records during a clinical research study to gather
statistical data such as frequency of clinical disorders, complications, use of
specific medical and nursing therapies, recovery from illness, and death to
investigate a new nursing intervention.

 Auditing-Monitoring
Nurses monitor or review records throughout the year to determine the degree to
which quality improvement standards are met. Deficiencies identified during
monitoring are shared with members of the health care team so that corrections
in policy or practice can be made. Quality improvement programs keep nurses
informed of standards of nursing practice to maintain excellence in nursing care.

1.8.2 Types of Records

Which type of records are kept in nursing? Take a minute to think about it and then
complete the following activity.

ACTIVITY 3.2
Write down in your notebook 3 records that are kept in nursing

Well done! Now compare your answers with what you read in the following section.

The main types of records kept in nursing are:

 Admission nursing history forms
 Flow sheets and graphic records
 Kardex and nursing care plan
 Computer records.
Let’s consider each type of form in detail below.

16
a) Admission Nursing History Forms
This form is completed when a client is admitted to a nursing care unity. The
history form guides the nurse through a complete assessment to identify relevant
nursing diagnosis or problems. It contains data that can be used as baseline
information to compare with changes in the clients condition. Each institution
designs its own history form based on its standard of practice and philosophy of
nursing care.

b) Flow Sheets and Graphic Records

Flow sheets are forms that allow nurses to quickly and easily enter assessment
data about the client, including vital signs and routine repetitive care, such as
hygiene measures, ambulation, meals, weights, and safety and restraint checks.
It provides health care team members with a quick assessment of a client’s
status.

c) Kardex and Nursing Care Plan

Kardex is a widely used, concise method of organizing and recording data about
a client. It makes information quickly accessible to all members of the health
team. The system consists of a series of cards kept in a portable index file. The
card for a particular client can be quickly turned up to reveal specific data. Often
Kardex data is recorded in pencil so that it can be changed and kept up to date.
The information on a Kardex may be organized into sections, for example:

 Pertinent information about the client, such as name, room number, age,
religion, marital status, admission date, occupation, and next of kin.
 List of medications, with the date of order and time of administration for each.
 List of intravenous fluids, with dates of infusions.
 List of daily treatment and procedures, such as irrigations, dressing changes,
postural drainage, or measurement of vital signs.
 List of diagnostic procedures ordered, such as endoscopic or laboratory tests.
 Allergies.

17
  Specific data on how the client’s physical needs are being met, such as type
of diet, assistance needed with feeding, elimination devices, activity, hygiene
needs, and precautions (use of side rails, among others).
 A problem list, stated goals, and a list of nursing approaches to meet the
goals and relieve the problems.

When caring for a client, the nurse has the best opportunity to assess and reassess
with the client the accuracy of the information and the effectiveness of treatment.

d) Computer Records:
A well designed database system can make the entry and retrieval of information a
relatively easy task for the nurse who uses it. Changes can be made easily to update
this record. Later as the needs of the nurse dictate, information about a particular
client, diagnosis, or physician can be recalled to the screen.

In addition to facilitating individualized clients care, computerized records can also

be beneficial to nurse-managers who may use the stored data to generate reports on
the acuity levels of clients on each unit.

1.8.3 Format for Writing Progress Reports

The systematic format for writing progress notes can be done using the following
mnemonics:
 SOAP
 SOAPIER
 APIE
 Flow sheet

Let’s look at what each mnemonic in turn.

1. SOAP stands for:

S - Subjective:
 History and symptoms of the present complaint or past problem
 What the patient or family tells you
O - Objective
18
  Physical examination
 Physiologic data
 X-ray
 Laboratory results
A - Assessment
 Diagnosis or present state of the problem

P - Plan (actions to be taken to relieve client’s problem)

 Therapy (treatment: medicines and procedures)
 Investigation (diagnostic)
 Education (Patient. education.)
 Referrals
 Follow up

2. SOAPIER stands for the following:

S - Subjective data.
O - Objective data
A - Assessment
P - Plan
I - Interventions
E - Evaluation: based on the patient’s response to the interventions
R - Revision to the plan or changes that must be made.

3. APIE stands for the following:

A - Assessment. Combines subjective and objective data with nursing diagnosis
P - Plan. Combines nursing actions with expected outcomes
I - Implementation
E - Evaluation

Table 5 below shows you how to use the SOAP mnemonic to write progress notes.

Table 5 : Example of SOAP format

Problem Date/Time SOAP NOTES

No 1 2-11-15 S – ‘My head hurts right in the back of my eyes. It is worse when bending
over’

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 14:30 O – Eyes closed, lights dim, hesitant to move head when questioned
A – Migraine headache probable secondary to intracranial pressure
P – Drink a lot of water
● Warm compresses to eyes
● Monitor temperature 4 hourly
● Analgesics
● Assess pain after medication and contact doctor

1.8.4 Guidelines for Documentation and Reporting

High quality documentation and reporting are necessary to enhance efficient,

individualized client care. Quality documentation and reporting have 5 important
characteristics. They should be
 factual
 accurate
 complete
 current
 organized.

We will look at each characteristic in further detail below.

1. Factual
A factual record contains descriptive, objective information about what a nurse
sees, hears, and smells. An objective description is the result of direct
observation and measurement. For example, ‘B/P 80/50, client diaphoretic, heart
rate 102 and regular’. The use of inference, for example, ‘client appear to be in
shock’ without supporting factual data is not acceptable because it can be
misunderstood.

The use of vague terms, such as appears, seems, or apparently, is not

acceptable because these words suggest that you are stating an opinion. For
example, a statement such as ‘the client seems anxious’, does not accurately
communicate facts. It also does not inform other caregiver of the behaviours
exhibited by the client that lead you to use the word anxious. When recording
subjective data, document the client’s exact words using quotation marks. For
example, when a client exhibits anxiety, you should record, ‘client states, ‘I feel
nervous’

20
2. Accurate
The use of exact measurements establishes accuracy. For example,
description such as ‘intake, 360 ml of water’ is more accurate than, ‘client drank
an adequate amount of fluid.’ These measurements can later determine whether
a client’s condition has changed. Charting that an abdominal wound is ‘5cm in
length without redness, drainage, or oedema’ is more descriptive than ‘large
wound healing well.’

Always use accepted abbreviations, symbols and system measures that can be
translated and understood by all the members of the health team. Correct
spelling demonstrates a level of competency and attention to details. Many terms
can easily be misinterpreted (for example dysphagia or dysphasia and dram or
gram). Some spelling errors can result in serious treatment error. For example,
the names of certain medications such as digitoxin and digoxin or morphine and
numorpan sound similar. You should write such terms carefully to ensure that
the client receives the correct medication.

Records need to reflect accountability during the time of entry. This is

accomplished if you only chart your observations and actions. The signature
holds you, responsible for the information you have recorded. If you inadvertently
omit information, it is acceptable to ask your colleagues to chart information in
your absence.

3. Complete
The information in a recorded entry or report needs to be complete and to contain
appropriate and essential information. Your written entries in the client’s medical
record describe the nursing care you administer and the client’s response.

4. Current
Timely entry is essential in the client’s ongoing care. To increase accuracy and
decrease unnecessary duplication, many health care facilities keep client records
by the bedside in order to facilitate immediate documentation of information as it
is collected from the client. Flow sheets offer a means of entering current
information quickly.

21
 The following are some of the activities or findings that you should communicate
immediately they occur:
 Vital signs
 Administration of medications and treatments
 Preparation for diagnostic test or surgery
 Change in client’s status and who was notified, (for example physician,
manager, client’s family)
 Admission, transfer, discharge, or death of a client
 Treatment for a sudden change in client’s status
 Client’s response to treatment or intervention

The 5th and final characteristic of good reporting and documentation is organization.

5. Organized
As a nurse, you need to communicate information in a logical order. For example,
an organized note describes the client’s pain, your assessment and interventions,
and the client’s response. When you write notes about a complex situation, you
should first make notes of what you wish to include before beginning to write in
the permanent legal record. Applying critical thinking skills and the nursing
process gives logical and order to nursing documentation.

1.8.5 Reporting and Conferring

Before you read any further, work through the following activity.

ACTIVITY 1.4
Write down in your notebook the meaning of report writing

Well done! Now compare your definition with the one in the following section.

Report Writing
Reporting is the verbal communication of data regarding a client’s health status,
needs, treatments, outcomes and responses (Eggland and Heinemann, 1994).

Let’s now look at the principles of report writing.

22
Principles of Writing
The following are the principles of report writing:
1. Give relevant information about the patient or ward situation
2. Ensure your report is clear and concise.
3. Ensure the receiver of the report has asked questions and clarified any
questions or issues s/he does not understand.
4. The receiver should be familiar with the information and instructions contained
in a written report (including abbreviations used).
5. Written reports must be signed in a recognized signature by people who
compile them.

Types of Ward Reports

There are several types of reports that are written by health workers. These include
the following:
 Summary (end of shift) report written and given during the exchange of shift or
transfer of a patient.
 Reports written when the nurses and physicians are making hospital rounds,
etc.
 Telephone reporting and orders -This is used when a nurse wants to inform a
physician of changes in a client’s condition or when communicating
information to other nurses in another department about client transfer.
 Incident reports of, for example, an accident during the shift such as a patient
falling or fire.

The summary report is written on admission and twice daily. That is, in the morning
by the night staff and in the evening by the day staff. The purpose of a writing this
report is to provide a permanent and accurate record of events and relevant data. A
report is a legal document and must be kept for a period of 5 years. It should also be
readily available for reference even when needed at short notice. The report must
have correct spellings particularly on drugs and only use universally accepted
abbreviations.

These reports contain the following basic information:

23
  Department where the patient is admitted, for example, an ICU report is
different from Maternity report
 Ward where patient is admitted
 Age of patient
 Condition of patient
 Information about the patient.

Report Writing on Admission or Transfer of Patient

On admission, a ward report should be written noting the time of admission, where
the patient has come from, reasons for admission or transfer to your ward.

You should record all social details, the condition of the patient on admission and the
general appearance which include the following:

 Clean or dirty
 Nutritional status
 Anxiety and restlessness
 Skin condition, for example, rash, scars, jaundice, cyanosis
 Dyspnoea
 Gait
 Any other abnormalities

The report should also include whether the patient has been seen by the Doctor or
not. If not, inform the Doctor. It should also include information on vital signs for the
baseline data and weight. Include whether a specimen of urine was collected and
tested , and if not indicate reasons. Record the results of the urine test if it is done.

Method of Hand Over

Shen a nurse takes over the ward, s/he must give undivided attention to the work.
This procedure should be conducted in a quite manner without unnecessary
interruptions. The nurse must remain in the ward to facilitate the following:

 Signing of the report and having it countersigned by the ward manager.

 Receiving and handing over to the nurse who is taking over.

24
  Correcting any mistakes and clarifying any issues right there and then.
 Reports should be given from bed to bed starting with acutely ill patients.

You have come to the end of this section on documenting and reporting. In the next
section, you will learn about hospital policies and regulation.

1.9 Hospital Policies and Regulation

Hospitals need good policies and procedures which are well regulated in order to
function effectively and efficiently and keep both employees and patients safe.

What is health policy?

Health policy is best understood as a set of overarching principles and goals that
dictate how care is delivered and accessed.

Importance of Policies
Health policies are important for the following reasons:

 They ensure patient safety by holding nurses accountable for following right
steps when caring for patients. They also improve patient safety by guiding
decisions in emergence moments.
 They help to improve internal communication and processes.
 They act as legal defence during lawsuits.

Types of policies
There are two main types of policies. These are
 administrative policies which cover day to day running of the hospital
 patient care policies which provide guidance on how nurses, doctors and
other health workers provide care to patients/clients.

Importance of Regulation In Healthcare

25
Why is it important to regulate healthcare? Take a minute or two to think about it
and then complete the following activity.

ACTIVITY 1.4
Write down in your notebook 3 reasons why it is important to regulate
health care.

Well done! Now compare your answers with what you read in the following section.

The following are some of the reasons why it is important to regulate healthcare:
 It helps to protect healthcare consumers from health risks,
 It provide a safe working environment for healthcare professionals and ensure
that public health and welfare are served by health programs
 It regulates works at all levels and ensures that t regulatory standards are
developed by government and private organizations as well
 It facilitates the standardization and supervision of healthcare and ensures that
healthcare bodies and facilities comply with public health policies and that they
provide safe care to all patients and visitors to the healthcare system.

The Nursing and Midwifery Council of Zambia (NMCZ) is a regulatory body for
nurses while other health professionals are regulated by Health Professions Council
of Zambia (HPCZ). We hope you still remember what you learnt about them in the
professional practice course.

As a way of reflecting on what you have learnt so far, answer the following
questions.

CHECKPOINT QUESTION NO. 3

1. Communication is a process of sending and receiving verbal and non-verbal messages.

True
False

2. The basic elements of communication Include; Referent, Sender, Message,

Channel,_______________ and __________________

3. Values are among the factors influencing communication

True

26
 False

Answers
1. True
2.
● Receiver &
● Feedback
3 True

You have come to the end of this unit. Let’s now review what you have covered.

1.10 Unit Summary

Well, in this unit you have learnt about interesting concepts
that have helped the nursing profession to provide
organized nursing care to clients. We started by discussing
the theories and models of nursing and how you can apply
the models in developing nursing plans. You have also
learnt about the nursing process and its 5 components of
assessment, nursing diagnosis, planning, implementation,
and evaluation. We have also described how to formulate
nursing care plans and given you examples drawn from the
various models of nursing. Further, you have learnt about
the interactive processes between you and the client, and
with members of the health care team. We hope you still
remember the importance of building a helping relationship
with your clients and the 4 stages of building this
relationship. You have also learnt how to communicate with
your patient and members of the health care team. In
addition, we have looked at the importance of
documentation and reporting and the standards and
different types of reports that the nurse is expected to
maintain. We have seen that effective communication,
documentation and reporting is vital to ensure that the
patient receives holistic care. Finally, we have discussed
the important role that hospital policies and regulation play
in keeping health care provision safe, professional and

27
 legal.

In the next unit, you will learn how the health care system in
Zambia is organised.

1.11. Self-assessment Test

1. High quality documentation and reporting are necessary to
enhance efficient, individualized client care. The following are
characteristics except;
a. Smart
b. Factual
c. Accurate
d. Complete
2. The main type of records kept in nursing is:
a. Admission nursing history forms
b. Flow sheets and graphic records
c. Kardex and nursing care plan
d. ALL of the above
3. The following are common issues in malpractice that are caused
by inadequate documentation except;
a. Not charting the correct time when events occurred
b. Documenting correct data
c. Failing to record verbal orders or failing to have them signed
d. Charting action in advance to save time
4. The Purpose of Documentation include the following except;
a. Legal documentation
b. Auditing-Monitoring
c. Research
d. None of the above

5. The following are some of the factors that influence

communication:

28
 a. Perceptions
b. Knowledge
c. Socio-cultural background
d. ALL the above
6. Nonverbal communication includes the following:
a. Facial expressions
b. Physical appearance
c. Both of the above
d. ALL the above
Answers
1. a
2. d
3. b
4. d
5. d
6. c

1.12 References and Further Reading

1. Ernest V. V, (1989). Clinical Skills and Assessment Techniques in
Nursing Practice, Foresman and Company, London.
2. Kozier. B. and Oliven R. (1991) Fundamentals of Nursing, Churchill
Livingstone, London
3. Margaret E. A (1979). McGraw-Hill Nursing Dictionary, McGraw-Hill
Book Company, London.
4. Orem, D: Nursing (1971): Concepts of Practice, , Mc Graw-Hill, New
York
5. Potter and Perry, (2005). Fundaments of Nursing, 6th ed. Mosby, St
Louis.
6. Smith S. and Duell D. (1982), Nursing Skills and Evaluation, National
Nursing Review, Kingsport Press, California: USA.
7. Meleis, A.I. (1997) Theoretical Nursing: Development and Progress.

29
 3rd Edition, Lippincott, Philadelphia

30
UNIT 2: HEALTH CARE SYSTEMS
2.1 Unit Introduction
Welcome to the second unit in this course. We hope you are finding your lessons
very interesting and the assessment questions very helpful. In the last unit, you
learnt about theories of nursing, nursing models and the interactive nursing care
process. In this unit, you will learn about healthcare systems. We will start by
discussing the organisation of Zambia’s healthcare system. We will then discuss the
providers of healthcare in Zambia. We will also discuss the factors affecting
influencing healthcare services and the human rights to health. Finally, we will
discuss the challenges in the healthcare delivery system. Let’s start by reviewing
the unit learning outcomes.

2.2 Unit Learning outcomes

Upon completion of this unit, you will be able to:

1. Describe the organisation of the healthcare system in Zambia

2. Identify the providers of healthcare services in Zambia
3. Describe the factors that influence healthcare services
4. Describe the human rights and standards that guide the
design of a health care system
5. Outline the key challenges in the healthcare delivery system

2.3 Organisation of Zambia’s Healthcare System

Take a minute to think of the different health facilities you may have been to and
then complete the activity below.

Activity 2.1
Write down in your notebook, the different types of health facilities
available in Zambia.

Well done! Now compare your answers with what you read in the section below.

31
The Ministry of Health (MoH) is a government sector that ensures that every
Zambian citizen receives efficient and quality health care. In Zambia, there are a
variety of healthcare facilities that offer care at various levels. These are:

 Community based healthcare

 Primary level healthcare
 First level referral hospitals
 Second level referral hospitals
 Third level referral hospitals
 Tertiary or specialised level hospitals

Let’s start by looking at the services offered in each level.

2.3.1 Community based Healthcare

Community based healthcare is offered in the community by community volunteers

such as community TB supporters, community health workers (CHWs), traditional
birth attendants (TBAs), Community Based Distributors (CBDs). These community
healthcare volunteers are responsible for the health of the community.

There are other services offered in the community such as hospices (nursing home).
These offer palliative care to terminally ill patients.

2.3.2 Primary Level Healthcare

This is essential health care delivered to patients at health posts and health centres
as close to the family as possible.

a. Health Post
This level of care is also offered at community level. The health posts are manned by
trained community health workers. They treat minor cases and refer difficult cases to
the health centres.

b. Health Centres

32
The health centres provide curative, promotive and preventive services. They have a
bed capacity of 20 and are manned by a clinical officer, enrolled midwife, enrolled
nurse and environmental technician (MoH, 1995). These operate 24 hours a day and
also offer maternity delivery services. They utilise the nearest district hospitals for
referrals.

2.3.3 First Level Referral Hospitals (District hospital)

These are peripheral hospitals which offer curative and rehabilitative health care to
patients referred from a health centre or by-passing a health centre. They have a
bed capacity of between 40-200 beds. They may also have a training institution such
as schools of Nursing and Midwifery. These mostly offer enrolled nursing and
midwifery programmes.

2.3.4 Second Level Referral Hospitals (General hospital)

They also offer curative and rehabilitative healthcare to patients referred from first
level referral hospitals. They have a bed capacity of between 200 and 500.
Examples of these hospitals include; Kasama, Livingstone and Mansa General
Hospitals.

2.3.5 Third Level Referral Hospitals (Central hospital)

They provide curative and rehabilitative care to patients referred from first and
second level referral hospitals. They have a bed capacity of above 500 beds.
Examples of these hospitals include: Kitwe and Ndola Central Hospitals.

2.3.6 Tertiary or Specialised Level Hospitals

They work on complicated or specialist cases referred by third level referral

hospitals. They use advanced equipment such as magnetic resonance imaging
(MRI) among others. Referred cases are managed by consultants. They have a bed
capacity of more than 1000 beds. Examples of these hospitals include: University
Teaching Hospital (UTH), Levy Mwanawasa University Teaching Hospital (LMUTH),
Chainama Hills Hospital (specialised in the management of mental disorders), Arthur
Davison Children’s’ Hospital and Cancer diseases Hospital in Lusaka.

33
Before you continue on to the next section on the providers of healthcare in Zambia,
answer the questions below as a way of reflecting on what you have learnt.
Checkpoint Question 1
For each question, circle the most appropriate answer

1. The delivery of essential health care to patients as close to the family as possible is
known as:
a. Specialised health care
b. Secondary health care
c. Primary health care
d. Tertiary health care

2. Third level referral hospitals have a bed capacity of:

a. 100
b. 1000
c. 200 to 500
d. 500

3. First level referral hospitals receive referrals from:

a. District hospitals
b. Health centres
c. Specialised level hospitals
d. Third level hospital

Answers:
Q 1. C
Q 2. D
Q 3. B

2.4 Healthcare Providers in Zambia

Healthcare providers in Zambia include: private hospitals and clinics; mission
hospitals and government or public hospitals and clinics. Let’s start by looking at
private hospitals and clinics.

2.4.1 Private Hospital and Clinics

Private hospital and clinics are owned by individuals and companies. With the
liberalisation of the economy following the change of government in 1991, many
private hospitals were established to supplement government hospitals. People who
seek healthcare services at these private healthcare centres are required to pay for
the services received. The major private hospitals are mainly found in Lusaka. They
are:
 Pearl of Health
34
  Care for Business
 Victoria Hospital
 Fairview Hospital
 Lusaka Trust
 TEBA Hospital
 Italian Orthopaedic Hospital

2.4.2 Mission Hospitals

Mission hospital have been in existence for many years in Zambia and most of them
are located in rural areas. The purpose of these hospitals was to provide treatment
to the faith followers of Christian organisations that provided spiritual guidance in that
area. For example, the Salvation Army who are predominantly found in Southern
province own Chikankata Hospital and Evangelical Church in Kasempa and Solwezi,
own Mukinge Mission Hospital in Kasempa. The Catholic Church owns the largest
number of hospitals. Mission hospitals are affiliated with an organisation called
Churches Association of Zambia (CHAZ).

2.4.3 Government or Public Hospitals and Clinics

These are hospitals that are operated and funded by the government. These
institutions charge a minimal fee for those that are seeking health services. However,
there are exemptions for epidemics, chronic diseases and the elderly patients or
patients under 5 years of age. Cost sharing schemes make the consumers feel and
own the services they are receiving. Examples of government hospitals include;
University Teaching Hospital (UTH), Ndola Central Hospital, Kasama General
Hospital and Mpika District Hospital, among others.

Before you continue on to the next section on factors influencing healthcare services,
answer the questions below as a way of reflecting on what you have learnt.

Checkpoint Question 2
Question: Mention the three main providers of healthcare in Zambia and give an
example of each

Answers
a. Mission Hospitals e.g. Mukinge Mission Hospital
b. Private hospital and Clinics e.g. Pearl of Health Hospital

35
 c. Government Hospitals e.g. the University Teaching Hospital
2.5 Factors Influencing Healthcare Services
There are many factors that can lead a population’s increased or decreased
utilisation of health care services.

Activity 2.2
Write down in your notebook, at least three factors that affect the
provision of healthcare services.

Well done! Compare your answers with the factors listed below.

These factors include:

 Socio-economic status
 Staffing levels
 Policies and beliefs of a nation
 Risk behaviours of a population
 Health status

Let’s start by looking at socio-economic status.

a) Socio-Economic Status (SES)

The socio-economic status (SES) of a community is a factor made up of many
factors such as education, income, and demographic characteristics (sex, age, and
ethnicity). It is believed that SES has a significant influence on utilisation behaviour
because of its effect on aspects such as need, recognition, and response to
symptoms; knowledge of disease; motivation to get well; and access or choice of
health services (Anderson, 1973; Hulka & Wheat, 1985).

It is well documented that persons of lower SES experience a greater degree of

disease and mortality (death). Despite these facts, research has shown that clinic
and hospital use is not reflective of their circumstances- especially among infants
and children. This disparity in use by young persons of lower SES can result in a
disproportionate amount of use when they are older (Hershey, Luft, & Gianaris,
1975).

36
Education and income usually result in higher use of healthcare services, especially
preventive visits and clinic visits; however, educated persons experience less acute
disease (Muller, 1986).

Research has shown that women have a slightly higher rate of utilisation than their
male counterparts (Hulka & Wheat, 1985).

Age is another significant aspect of SES. Although elderly persons use more health
services, it is not equally distributed among the whole population. Research has
shown how other factors, such as the presence of chronic disorders (health status),
risk behaviours (for example, smoking), and access to care, also play an important
role in how and why the aged use healthcare services. This is an excellent
illustration of the multi-factorial nature of health care utilisation and the faults of a
short-sighted approach to health policy decisions (Anderson, 1973; Hershey, Luft, &
Gianaris, 1975; Muller 1986).

b) Staffing Levels
When there are no trained health personnel, there will be less people accessing
healthcare.
Staffing levels are as important as SES and a large part of the literature illustrates
that its relationships with health care utilisation is straight forward. An increase in the
proportion of doctors and nurses available or access to doctors in a community
consistently results in an increase in health care utilisation of all types. This indicates
that many patients will use or be encouraged to use services when the physician
services are made available (Barer, Evans, & Labelle, 1988; Hulka & Wheat, 1985).

c) Policies and Beliefs of a Nation

Government policies have an influence on how people utilise healthcare services. If
governments make deliberate policies to take services closer to the people, this
increases accessibility.

Government policies and the values of a country can have a direct effect on health
care utilisation. When a country wants to increase the use of healthcare services by

37
the population, it can create policies in order to do so. Creation of health posts in
Zambia is one of such policies. This policy will take services closer to the people.

d) Risk Behaviour and Health Care Utilisation

Utilisation of healthcare services increase when people are aware of health risks.
The best example in Zambia, is the demand for male circumcision, cervical cancer
screening and voluntary counselling and testing (VCT) for HIV/AIDS.

Policies, such as the enforcement of wearing seatbelts in vehicles, have also helped
to reduce the effects of risk behaviours that can have a significant impact on
healthcare utilisation. Unfortunately, government efforts to reduce other risk
behaviours such as smoking and alcohol and drug abuse have not been effective.
Research has shown that lifetime health costs of smokers are 47% higher despite
the lower life expectancy of smokers (Hodgson, 1992; Rice et al., 1986).

e) Health status and Healthcare Utilisation

Health status is the most important factor associated with increased health care
utilisation. There is consistent evidence that shows that lower health status of a
population directly results in increased health care utilisation of all types (that is,
clinic visits, physician visits, and hospitalisation) (Anderson, 1973; Hershey, Luft, &
Gianaris, 1975; Hulka & Wheat, 1985; Muller, 1986).

Before you continue to the next section on the right to healthcare, answer the
questions below as a way of reflecting on what you have learnt.

Checkpoint Question 3
Write down four factors that influence utilisation of healthcare services and give
an example of how each of them influences healthcare utilisation.

Answers:
a. Socio-economic status for example Education and income usually result in
higher use of health care
b. Staffing levels for example an increase in the proportion of doctors and
nurses available results in an increase in health care utilisation of all types
c. Policies and beliefs of a nation for example creation of health posts in Zambia
has helped take services closer to the people thereby increasing utilisation of
healthcare services
d. Risk behaviours of a population for example reduced risk behaviours such as
alcohol abuse, unprotected casual sex leads to a healthier population and this

38
 leads to reduced utilisation of healthcare services
e. Health status for example lower health status of a population directly results
in increased healthcare utilisation of all types (that is, clinic visits, physician
visits, and hospitalisation)

2.6 The Right to Health Care

The human right to health means that everyone has the right to the highest
attainable standard of physical and mental health, which includes access to all
medical services, sanitation, adequate food, decent housing, healthy working
conditions, and a clean environment.

The human right to healthcare means that hospitals, clinics, medicines, and doctor’s
services must be accessible, available, acceptable, and of good quality for everyone,
on an equitable basis, where and when needed.

The design of a healthcare system must be guided by the following key human rights
standards and principles:

a. Universal Access
Access to healthcare must be universal, guaranteed for all on an equitable basis.
Healthcare must be affordable and comprehensive for everyone, and physically
accessible where and when needed.

b. Availability
Adequate healthcare infrastructure (for example hospitals, community health
facilities, and trained healthcare professionals), goods (for example drugs and
equipment), and services (for example primary care and mental health) must be
available in all geographical areas and to all communities.

c. Acceptability and Dignity

Healthcare institutions and providers must respect dignity, provide culturally
appropriate care, be responsive to needs based on gender, age, culture, language,
and different ways of life and abilities. They must respect medical ethics and protect
confidentiality.
39
 d. Quality
All healthcare must be medically appropriate and of good quality, guided by quality
standards and control mechanisms, and provided in a timely, safe, and patient-
centred manner.

The human right to health also entails the following procedural principles, which
apply to all human rights:

e) Non-Discrimination
Health care must be accessible and provided without discrimination (in intent or
effect) based on health status, race, ethnicity, age, sex, sexuality, disability,
language, religion, national origin, income, or social status.

f) Transparency
Health information must be easily accessible for everyone, enabling people to
protect their health and claim quality health services. Institutions that organise,
finance or deliver healthcare must operate in a transparent way.

g) Participation
Individuals and communities must be able to take an active role in decisions that
affect their health, including in the organisation and implementation of healthcare
services.

h) Accountability
Private companies and public agencies must be held accountable for protecting the
right to healthcare through enforceable standards, regulations, and independent
compliance monitoring.

The Human Right to Health is protected in:

 Article 25 of the Universal Declaration of Human Rights
 Article 12 of the International Covenant on Economic, Social and Cultural
Rights
 Article 24 of the Convention on the Rights of the Child

40
  Article 5 of the Convention on the Elimination of All Forms of Racial
Discrimination
 Articles 12 & 14 of the Convention on the Elimination of All Forms of
Discrimination Against Women
 Article XI (11) of the American Declaration on Rights and Duties of Man
 Article 25 of the Convention on the Rights of Persons with Disabilities

Before you continue on to the next section on challenges in the healthcare delivery
system, answer the questions below as a way of reflecting on what you have learnt.

Checkpoint Question 4
1. List six rights to health care
2. Which article in the international human rights addresses the convention on
the rights of children

Answers:
Q 1. Health care should be;
 Universally Accessible
 Available
 Acceptable and of Dignity
 Of Quality
 Non-Discriminatory
 Transparency
 Participative
 Provide Accountability

Q 2. Article 24

Now that you know your rights to healthcare, it is your responsibility to educate the
patients of their rights to healthcare and aid in the implementation of these rights. In
the next section, we will discuss the challenges faced in healthcare delivery system.

2.7 Challenges in Healthcare Delivery System

There are many problems in the healthcare delivery system and you may have heard
of or experience some of them or talked about them with your friends.

Activity 2.3
Write down in your notebook, at least three challenges experienced
in the healthcare delivery system.

41
Good attempt! Compare your answers with the factors discussed in the section
below.

a. Changes in legislation
With the enactment of the Nurses and Midwifery Act of 1997, the scope of practice
for nurses has been broadened. This means that nurses are now able to enter
private practice, provide prescription and perform invasive procedures. Challenges
have however arisen due to the lack of specialisation necessary to gain the required
competences.

b. Globalisation
This is the tendency of the world to function as one entity. This tendency results in
uniformity and standardisation of procedures. This means that Zambia’s Registered
Nurse curriculum should expose and equip students to function anywhere in the
world. However, some of the challenges arise due to limited equipment and
machinery to enable the learner to practice and sharpen their skills to meet global
standards.

c. Technological changes
New technology has brought a variety of new machinery such as the ones used in
the intensive care unit (ICU). These machineries are improving the way care is being
given. These technological changes means that nurses need continuous education
to upgrade their knowledge and learn how to operate these machines. The
emergence of distance education and e-learning pose a challenge due to limited
internet facilities and the learner’s knowledge of information and communications
technology (ICT).

d. Political and economic forces

Policies made by the government affect the way care is given. The reduction of
funding towards the social sector such as health has an effect on nursing practice.
Reduction of funding means that medical and surgical supplies will be inadequate
and so nurses will be forced to be improvise. This compromise the quality of care.

e. Increased disease burden and changing disease patterns

42
The HIV pandemic has caused some new conditions to resurface. There have also
been a significant changes in the presentation of common conditions. There is an
increase in non-communicable diseases like cancers and hypertension.

f. Changes in the nursing education system

A new curriculum has been introduced to equip student nurses with new concepts in
the health sector. Some of the new concepts include integrated management of
childhood illnesses (IMCI) and SMART care. Introduction of distance education and
direct entry at degree level poses the challenge of close supervision of learners due
limited number of lecturers in departments of nursing science.

g. Shortages of nursing staff

The shortages of nurses can be attributed to several factors such as poor salaries
and poor conditions of services, increasing deaths among nurses, poor infrastructure
and poor image of the nursing profession. This leads to poor health service delivery.

h. Human rights
With a lot of people becoming aware that health is not a privilege but a right, there is
a greater challenge for the accountability of the work of nurses. The awareness of
human rights has brought increased demand for quality care. More people are
getting educated and as such, they cannot accept mediocrity in the healthcare
services they receive

Before you continue on to the unit summary, answer the questions below as a way of
reflecting on what you have learnt.

Checkpoint Question 5
State True or False

Q:The following pose problems in healthcare delivery system and challenges for
the future:
a. Shortages of health staff
b. Awareness of human rights
c. Scope of practice
d. Changes in the disease patterns
e. Poor delivery of health care
f. New machinery
g. Training of nurses in HIV/AIDS

43
Answers:
a. T
b. T
c. F
d. T
e. F
f. T
g. F

2.8 Unit Summary

In this unit, we started by describing the organisation of
Zambia’s healthcare system. You learnt about the different
levels of healthcare facilities, from community based
healthcare to tertiary or specialised hospitals. We also
looked at the three healthcare providers in Zambia: private
hospitals and clinics, mission hospitals and government or
public hospitals and clinics. Next we discussed the factors
influencing healthcare services. You learnt about the
influence of: socio-economic status; staffing levels; policies
and beliefs of a nation; risk behaviours of a population; and
health status. We also discussed the human right to
healthcare. You learnt about the principles of: universal
access; availability; acceptability and dignity; and quality. In
the final section, we discussed the challenges in the
healthcare delivery system. You learnt about challenges
such as: changes in legislation; globalisation; changes in
technology; political and economic forces; increased
disease burden; changes in nursing education; shortages of
nursing staff and human rights.

In the next unit, you will learn about First Aid Management
of Emergencies.

44
 2.9 Self-Assessment Questions
1. Some of Challenges in Healthcare Delivery System
include;
a. Changes in legislation
b. Globalisation
c. Technological changes
d. Transparency
2. The design of a healthcare system must be guided by the
following key human rights standards and principles except:
a. Universal Access
b. Acceptability and Dignity
c. Non-Discrimination
d. None of the above
3. The following include Factors Influencing Healthcare
Services except;
a. Socio-economic status
b. Staffing levels
c. Globalization
d. Policies and beliefs of a nation
4. In Zambia, there are a variety of healthcare facilities that
offer care at various level, these include;
a. Community based healthcare
b. Primary level healthcare
c. First level referral hospitals
d. ALL of the above
5. ----------------------------level work on complicated or
specialist cases referred by third level referral hospitals.
Answers
1. d
2. d
3. c
4. d
5. Tertiary or Specialised Level Hospitals

45
2.10 References and Further Reading
1. Anderson, J. G. (1973). Health services utilization: Framework and
review. Health Services Research, 8(3), 184-99.
2. Barer, M. L., Evans, R. G., & Labelle, R. J. (1988). Fee controls as
cost control: Tales from the frozen North. Milbank Quarterly, 66(1),
1-64.
3. Hershey, J. C., Luft, H. S., & Gianaris, J. M. (1975). Making sense
out of utilization data. Medical Care, 13(10), 838-54.
4. Hodgson, T. A. (1992). Cigarette smoking and lifetime medical
expenditures. Milbank Quarterly, 70(1), 81-125.
5. Hulka, B. S., & Wheat, J. R. (1985). Patterns of utilization. The
patient perspective. Medical Care, 23(5), 438-60.
6. Johansen, H., Nair, C., & Bond, J. (1994). Who goes to the
hospital? An investigation of high users of hospital days. Health
Reports, 6(2), 253-77.
7. Muller, C. (1986). Review of twenty years of research on medical
care utilization. Health Services Research, 21(2 Pt 1), 129-44.
8. Rice, D. P., Hodgson, T. A., Sinsheimer, P., Browner, W.,
Kopstein, A. N. (1986). The economic costs of the health effects of
smoking, 1984. Milbank Quarterly, 64(4), 489-547.

46
UNIT 3: FIRST AID MANAGEMENT OF EMERGENCIES
3.1 Unit Introduction
Welcome to the third unit in this course. In the last unit, you learnt about healthcare
systems. In this unit, you will learn about the first aid management of emergencies.
We will start by defining key terms used in first aid. We will then discuss the aims
and principles of first aid. We will also discuss methods of bandaging, splinting, lifting
and transporting casualties. Finally, we will discuss the first aid management of
select medical emergencies. Let’s start by reviewing the unit learning outcomes.

3.2 Unit Learning Outcomes

Upon completion of this module, you will be able to:
1. Define key terms used in first aid
2. Outline the aims and principles of first aid
3. Describe the methods of bandaging and splinting.
4. Describe the methods of lifting and transporting
casualties.
5. Describe the first aid management of the following
emergencies:
 Asphyxia
 Cardiac arrest
 Haemorrhage
 Shock
 Unconsciousness
 Head injury
 Fractures, sprains and dislocations
 Spinal and chest injuries
 Drowning
 Wounds
 Burns and scalds
 Bites and stings
 Fits and infantile convulsions
 Fainting and heat exhaustion

47
  Fire drills and ward accidents
 Poisoning
 Ingesting corrosives, strong acids and alkaline
substances

3.3 Definition of Key Terms used in First Aid

Activity 3.1
In your own words, write down a definition for first aid and
medical emergency in your note book.

Well done! Compare your answers with the definitions given below.

3.3.1 First Aid

This is the immediate care given to a person who has been involved in an accident
or has suddenly been taken ill before reaching a health facility.

3.3.2 Medical Emergency

This is an injury or serious illness that occurs suddenly whereby if it not treated
immediately could cause death or serious harm to an individual.

3.4 Aims and Principles of First Aid

It is important for you to acquire knowledge on the reasons why first aid is provided
and the guiding principles to follow when offering first aid to casualties. The aims and
principles of first aid are described below.

Aims of First Aid

 To preserve life.
 To minimise the effects of injury.
 To promote recovery.
 To relieve pain and distress.
 To prevent the condition from worsening.
 To deliver casualties in good condition to hospital.

48
Principles of First Aid
The following are the principles of first aid:
 To treat the most urgent conditions. For example, severe haemorrhage, shock
or impaired breathing.
 Remove the patient from danger or remove further danger from the casualty.
For example a child who is caught up in a fire should be removed immediately
and taken to a safer place before any treatment.
 Assess the level of consciousness in a patient who is unconscious and don’t
give anything by mouth.
 Meanwhile call for help and arrange for transport.
 Handle patients with care and if there is a suspected fracture, support the part
involved carefully.
 Use your common sense.
 Control people standing by.
 Avoid cross infection by covering cuts on your hands with waterproof dressing
and wear disposable gloves if available.
 Don’t attempt too much alone.
 Control your feelings and know your limits.
 Make a call to inform the necessary authorities.
 Set priorities in the casualties – severe, moderate, and mild.

Let us now look and at some of the first aid techniques that can be used to manage
emergency conditions, starting with bandaging and splinting.

3.5 Bandaging and Splinting

Casualties of road traffic accidents usually have wounds and broken bones that
wneed bandaging and splinting.

Bandaging and splinting involve the application of a strip of woven materials to hold
a wound dressing or splint in place. Plain white roller bandages are commonly used.
Conforming bandages and elastic ones have more ‘give’ and are easier to adopt
round shapes of extremities and even contours.

49
3.5.1 Bandaging

A bandage is a strip of material such as gauze used to protect, immobilise,

compress, or support a wound or injured body part. Gauze is a type of material used
when covering a wound.

Types of Bandages
Bandages are available in different types, from generic cloth strips, to specialised
shaped bandages designed for a specific limb or part of the body. Bandages can
often be improvised as the situation demands, using clothing, blankets or other
materials.

The types of bandages we will look at in this section are:

 Gauze bandages
 Compression bandages
 Triangular bandages
 Tube bandages

Let’s start by describing gauze bandages.

a. Gauze bandages
This is the most common type of bandage. It is a simple woven strip of material, or a
woven strip of material with a Telfa absorbent barrier to prevent adhering to wounds,
which can come in any number of widths and lengths. A gauze bandage can be used
for almost any bandage application, including holding a dressing in place.
b. Compression bandages
The term 'compression bandage' describes a wide variety of bandages with many
different applications. This type of bandage is used to apply pressure to control
bleeding (Medical Dictionary, 2012).

Figure 1 below gives an illustration of compression bandaging.

50
Figure 1: An example of compression bandaging

There are 3 types of compression bandages. These are:

 Short stretch compression bandages
 Long stretch compression bandages
 Triangular bandage

Let’s look at each type in turn.

 Short stretch compression bandages

These are good for protecting wounds on the hands, especially the fingers.
They can also be applied to the limbs (usually for treatment of lymphedema or
venous ulcers). This type of bandage is capable of shortening around the limb
after application and therefore does not exert pressure during inactivity. This
dynamic is called resting pressure and is considered safe and comfortable for
long-term treatment. Conversely, the stability of the bandage creates very
high resistance to stretch when pressure is applied through internal muscle
contraction and joint movement. This force is called working pressure. A lot of
elastic is contra-indicated because not only does it help improve the condition
but it can cause an aching leg. If a patient has Peripheral Arterial Disease
(PAD), elastic can aggravate an already poor arterial supply. It is therefore
best to avoid elastic if you want a good therapeutic effect.

 Long stretch compression bandages

These have long stretch properties, meaning their high compressive power
can easily be adjusted. However, they also have a very high resting pressure
and must be removed at night or if the patient is in a resting position.

51
 c. Triangular bandage
Also known as a cravat bandage, a triangular bandage is a piece of cloth cut
into a right-angled triangle, and often provided with safety pins to secure it in
place. It can be used fully unrolled as a sling, folded as a normal bandage, or
for specialised applications, such as on the head. One advantage of this type
of Bandage is that a makeshift bandage can be made from a fabric scrap or a
piece of a t-shirt. The Boy Scouts popularised the use of this bandage in
many of their first aid lessons. They carry a cravat bandage with their uniform
in the form of a neckerchief. When used to make a sling for humerus or
forearm fractures, it is best to tie the middle point. This goes under the elbow
to help secure and restrict further movement of the arm. Next, take one of the
long ends of the triangular bandage and tuck it under the arm. Then pull it
over the injured shoulder and behind the neck. The other long end should be
placed over the opposite shoulder and tied with the other end on the side of
the neck (not the back of the neck because of the pressure it places on it).
Make sure the sling covers the arm from the elbow to or a little beyond the
hand. Additionally, you can also place something round in the patients hand to
place the arm in a functioning position.

d. Tube bandage
A tube bandage is applied using an applicator, and is woven in a continuous circle. It
is used to hold dressings or splints on to limbs, or to provide support to sprains and
strains, and it stops any bleeding.

Application of Bandages
Bandages can be helpful in first aid if they are applied correctly without causing
negative effects on the patient. To achieve this, one should follow the principles and
methods indicated below.

General principles of Applying Bandages

A bandage must be snug. It is useless if the bandage is too loose or too tight, as it
can interfere with blood circulation.

To ensure that circulation is not interfered with:

52
  Never apply a tight circular bandage around a person’s neck as it may cause
strangulation.
 Loosen the bandage immediately if the patient complains of numbness and
tingling sensation.
 Watch for swelling, changes of colour or coldness of tips of fingers or toes
indicating interference with circulation.
 Leave the patient’s finger tips exposed when the splint or bandage is applied
to the arm or leg.

Methods of applying bandages

a. Figure of eight: anchor the bandage with one or two turns around the palm or
the hand. Carry it diagonally across the front of the wrist and back of the palm.
This figure of eight manoeuvre is repeated as many times as it is necessary to
fix the dressing properly. Complete by tying off.
b. Spiral bandaging: anchor the bandage. Continue to encircle the area to be
covered by use of spiral turns, spaced so that they don’t overlap. It can be
closed by continuing to encircle with spiral turns until all gaps are closed.
c. Circular turns: simply encircle the part with each layer of bandage
superimposed on the previous one. It is the simplest of all bandaging turns.
d. Fingertip bandage: this is a series of back and forth turns called recurrent
turns, held in place by circular and spiral turns. It is secured by tying off.
e. Arm sling: involves the use of a triangular bandage. The broad part should be
folded and used to hold and support the arm. Then two loose ends are tied
around the neck.

Now that you have a better understanding of bandaging, let’s look at splinting.

3.5.2 Splints and Casts

Splinting is the immobilisation of a joint or injury site so that healing can take place.
You can use splints to immobilise an extremity that has been injured. A splint can be
a rigid or flexible device that maintains a displaced or movable part in position, also
used to keep it in place. The injury can be a broken bone or a severe sprain.
Casts and splints are hard wraps used to support and protect injured bones,
ligaments, tendons, and other tissues. They help broken bones heal by keeping the

53
broken ends together and as straight as possible. Casts and splints also help with
pain and swelling and protect the injured area from more harm.
A cast wraps all the way around an injury and can only be removed in the doctor's
office. All casts are custom-made with fiberglass or plaster.

A splint is like a “half cast.” The hard part of a splint does not wrap all the way
around the injured area. It is held in place by an elastic bandage or other material.
Unlike casts, splints can be easily removed or adjusted. Many splints are custom-
made from fiberglass or plaster. Others are premade (“off-the-shelf”) and come in
lots of shapes and sizes for different injuries.

Purpose of Splinting

 Splinting provides stabilisation of the injury and provides some amount of pain
relief and prevention of further injury.
 Splints are often applied as a temporary measure until more definitive
orthopaedic care is initiated.
 Correction and prevention of contractures.
 Positioning or supporting during function.

Position of Function
When applying splints, there is a specific position of safe immobilisation for every
joint that requires careful consideration, which is known as the position of function.
Without considering the position of function, the patient may be exposed to
contractures, stiffness, limited range of motion and inadequate healing.

Types of Splints
a. Soft Splints
Splinting often starts either at home or by emergency medical providers. The
simplest form of splinting is soft splinting, which can be provided with the use of a
pillow or blankets. The splint is secured around the area of injury and held in place
with tape or ties. Even a soft splint will provide the patient some support for the
injured extremity and comfort. Pre-made soft splints, which are occasionally used for

54
hand or wrist injuries, will slide on like a glove and are adjusted with the use of laces
to tighten and conform the splint.

b. Hard Splints
Hard splints are another type of splint used for extremity injuries. Hard splints can be
as simple as using a cardboard box or a padded board. Some hard splints can be
made out of fiberglass or plaster that can be moulded to fit the patient's extremity.
Splints made from plaster or fiberglass are named according to the area of injury
they are being applied to. A splint specifically used to treat a thumb injury is called a
thumb spica. For a wrist or forearm injury, the volar splint is used, and for injuries to
the hand and fist area, a boxer splint is applied. Pre-made aluminium splints are
often used to stabilise fingers.

Figure 2 below gives an illustration of hard splints

Figure 2: An example of hard splints

(Source: https://www.google.co.zm/search?q=illustration+of+a+hard+splint)

c. Air or Vacuum Splint

Air or vacuum splints are a type of splint available and used by some healthcare
providers for treating orthopaedic injuries. Air or vacuum splints conform well to the
injured extremity. According to ‘Sheehy's Emergency Nursing Principles and
Practice,’ excessive pressure from these type splints can compromise circulation.
The air splints also stick to the skin and can cause irritation.
The air or vacuum splint is illustrated in figure 3 below.

55
Figure 3: An example of air or vacuum splints

(Source: https://www.google.co.zm/search?q=vacuum+splint)

d. Traction Splints
Traction splints are used to support a broken bone, decrease the amount of
deformity and provide traction to keep the bones aligned and to prevent them from
moving. Traction splints are often used for injuries in either the femur or mid-shaft
lower leg.
The traction splint is illustrated in figure 4 below.

Figure 4: An example of traction splints

(Source: https://www.google.co.zm/search?q=vacuum+splint)

General Fracture Management Principles

It is important to maintain good anatomic fracture alignment throughout treatment.
Acceptable angular deformity in the hand varies depending on the fracture site.
Rotational deformity in the hand is never acceptable.

56
Stable fractures are generally re-evaluated within one to two weeks following cast
application to assess cast fit and condition, and to perform radiography to monitor
healing and fracture alignment. Hand and forearm fractures, however, are often re-
evaluated within the first week.

Displaced fractures require closed reduction, followed by post-reduction radiography

to confirm bone alignment. Both displaced and unstable fractures should be
monitored vigilantly to ensure maintained positioning. If reduction or positioning is
not maintained, urgent referral to an orthopaedic subspecialist is warranted.

Methods of Splinting
The following are the splints and casts used for the upper extremity

a. Ulnar gutter splint

The ulnar gutter splint is used in the following cases:
 Non-displaced, stable fractures of the head, neck, and shaft of the fourth or
fifth metacarpal with mild angulation and no rotational deformities.
 Non-displaced, non-rotated shaft fractures and serious soft tissue injuries of
the fourth or fifth, proximal or middle phalanges.
 Boxer's fractures (distal fifth metacarpal fractures, the most common injury for
which ulnar gutter splint/cast used).

Application: the splint begins at the proximal forearm and extends to just beyond the
distal inter phalangeal (DIP) joint. Cast padding is placed between the fingers.

Position of Function: the wrist is slightly extended, with the metatarsophalangeal

(MCP) joints in 70 to 90 degrees of flexion, and the proximal interphalangeal (PIP)
and DIP joints in 5 to 10 degrees of flexion. The ulnar gutter splint is illustrated in
figure 5 below.

57
Figure 5: An example of ulnar gutter splinting

(Source: Kulkarni, 2013 available at:

http://emedicine.medscape.com/article/80165-overview#a15)

b. Ulnar gutter cast

The ulnar gutter cast can be used as a definitive or alternative treatment of injuries
commonly treated with ulnar gutter splint.

Application: the cast is applied 24 to 48 hours or more after the initial injury to allow
swelling to decrease. Placement of the casting materials is similar to that of the ulnar
gutter splint, except the plaster or fiberglass is wrapped circumferentially.
The ulna gutter cast is illustrated in figure 6 below.

Figure 6: An example of an ulnar gutter cast

58
 c. Radial gutter splint
This splint can be used in the following situations:
 Non-displaced fractures of the head, neck, and shaft of the second or third
metacarpal without angulation or rotation.
 Non-displaced, non-rotated shaft fractures and serious injuries of the second
or third, proximal or middle phalanx.
 Initial immobilisation of displaced distal radius fractures.

Application: the splint runs along the radial aspect of the forearm to just beyond the
DIP joint of the index finger, leaving the thumb free. Cast padding is placed between
the fingers.

Position of function: the wrist is placed in slight extension, with the MCP joints in 70
to 90 degrees of flexion, and the PIP and DIP joints in 5 to 10 degrees of flexion.
The radial gutter splint is illustrated in figure 7 below.

Figure 7: An example of a radial gutter splint

(Source: http://emedicine.medscape.com/article/80108-overview)

d. Radial gutter cast

This cast is used for the definitive or alternative treatment of fractures initially
managed with a radial gutter splint.
Application: placement of the casting materials is similar to that of the radial gutter
splint, except the plaster or fiberglass is wrapped circumferentially. The cast is
usually placed two to seven days after the initial injury to allow for resolution of
swelling.

59
The radial gutter cast is illustrated in figure 8 below.

Figure 8: Radial gutter cast

Pearls and Pitfalls: minimal angulation or rotation at the fracture site may cause
functional problems, such as difficulty with grasp, pinch, or opposition. Therefore,
meticulous evaluation and follow-up are essential.

e. Thumb spica splint

This splint can be used in the following situations:
 Suspected injuries to the scaphoid.
 Stable ligamentous injuries to the thumb.
 Initial treatment of non-angulated, non-displaced, extra-articular fractures of
the base of the first metacarpal.
 De Quervain tenosynovitis.
 First carpometacarpal joint arthritis.

Application: the splint covers the radial aspect of the forearm, from the proximal one
third of the forearm to just distal to the interphalangeal joint of the thumb, encircling
the thumb.

Position of function: The forearm is in the neutral position with the wrist extended to
25 degrees and the thumb in a position of function (that is, ‘holding a soda can’).

Pearls and Pitfalls: immobilisation of the thumb with a removable splint after a
ligamentous injury is strongly preferred by patients, and the functional results are
equal to those of plaster cast immobilisation after surgical and nonsurgical treatment.
60
 f. Thumb spica cast
This cast can be used in the following situations:
 Suspected or non-displaced, distal fractures of the scaphoid.
 Non-angulated, non-displaced, extra-articular fractures of the base of the first
metacarpal.

Application: the cast uses the same position of function as described for a thumb
spica splint, but requires circumferential application of casting materials.
The thumb spica cast is illustrated in figure 9 below.

Figure 9: An example of a thumb spica cast

Pearls and Pitfalls : because these types of fractures are often serious and have a
high rate of complications, long-term splinting is not an appropriate definitive
treatment. Angulated, displaced, incompletely reduced, or intra-articular fractures of
the first metacarpal base should be referred for orthopaedic subspecialist evaluation.

Non-displaced distal fractures of the scaphoid have a greater potential to heal and
may be placed in a short arm thumb spica cast and re-evaluated out of the cast by

61
radiography in two weeks. Non-displaced fractures of the middle or proximal one
third of the scaphoid are treated with a long arm thumb spica cast initially and require
vigilant monitoring for non-union.

g. Buddy taping (dynamic splinting)

This splint can be used in the following situations:
 Minor finger sprains.
 Stable, non-displaced, non-angulated shaft fractures of the proximal or middle
phalanx.

Application: the injured finger is taped to the adjacent finger for protection and to
allow movement.

h. Dorsal extension-block splint

This splint can be used in the following situations:
 Larger, middle phalangeal volar avulsions with potential for dorsal
subluxation.
 Reduced, stable PIP joint dorsal dislocations.

Application: in reduced, volar avulsion fractures, the splint is applied with the PIP
joint at 45 degrees of flexion and secured at the proximal finger, allowing flexion at
the PIP joint. With weekly lateral radiography, the flexion is decreased 15 degrees
until reaching full extension over four weeks. Buddy taping should follow. Treatment
of reduced PIP joint dislocations is similar, but requires a starting angle of 20
degrees.

The dorsal extension-block splint is illustrated below.

62
Figure 10: An example of a dorsal extension-block splint

i. Aluminium u-shaped splint

This splint is used for distal phalangeal fractures.
Application: the aluminium splint wraps from the dorsal fingertip around to the volar
fingertip and immobilizes only the DIP joint in extension.

j. Mallet finger splints

This splint is used in the case of avulsion of the extensor tendon from the base of the
distal phalange (with or without an avulsion fracture).
Application: the DIP joint is placed in slight hyperextension with a padded dorsal
splint, an unpadded volar splint, or a prefabricated mallet finger splint. Continuous
extension in the splint for six to eight weeks is essential, even when changing the
splint. Compliance is assessed every two weeks. Night splinting for an additional two
to three weeks is recommended.

k. Volar/dorsal forearm splint

This splint is used in the following situations:
 Soft tissue injuries of the hand and wrist
 Temporary immobilisation of carpal bone dislocations or fractures (excluding
scaphoid and trapezium)

63
Application: the splint extends from the dorsal or volar mid-forearm to the distal
palmar crease).
Position of Function: the wrist is slightly extended.
The volar/dorsal forearm splint is illustrated in figure 11 below.

Figure 11: An example of a volar wrist splint

Pearls and Pitfalls:

The splint does not limit forearm pronation and supination, and is generally not
recommended for distal radial or ulnar fractures. A recent study, however,
demonstrated that compared with casting for definitive treatment of wrist buckle
fractures in children, a removable plaster splint improves physical functioning and
satisfaction, with no difference in pain or healing rates.

l. Short arm cast

This cast is used in the following situations:
 Non-displaced or minimally displaced fractures of the distal wrist, such as
Colles and Smith fractures or greenstick, buckle, and epiphyseal fractures in
children.
 Carpal bone fractures other than scaphoid or trapezium.

Application: the cast extends from the proximal one third of the forearm to the distal
palmar crease volarly and just proximal to the MCP joints dorsally.

64
Position of function: the wrist is in a neutral position and slightly extended; the MCP
joints are free.

Pearls and Pitfalls

These are the same as for a forearm splint.

m. Single sugar-tong splint

This splint is used for acute management of distal radial and ulnar fractures.
Application: he splint extends from the proximal palmar crease, along the volar
forearm, around the elbow to the dorsum of the MCP joints).
Position of function: the forearm is neutral and the wrist is slightly extended.
The single sugar-tong splint is illustrated in figure 12 below/

Figure 12: An example of a single sugar-tong splint

Pearls and Pitfalls

The splint stabilises the wrist, elbow and limits, but does not eliminate forearm
supination and pronation.

n. Long arm posterior splint

65
This splint is used in the following situations:
 Acute and definitive management of elbow, proximal and mid-shaft forearm,
and wrist injuries.
 Acute management of distal radial (non-buckle) and/or ulnar fractures in
children.

Application: the splint extends from the axilla over the posterior surface of the 90-
degree flexed elbow, and along the ulna to the proximal palmar crease.

Pearls and Pitfalls

The posterior splint is not recommended for complex or unstable distal forearm
fractures.

o. Long arm cast

This cast is used for the definitive treatment of injuries initially treated with a posterior
splint.
Application: the cast extends from the mid-humerus to the distal palmar crease
volarly and just proximal to the MCP joints dorsally.

Position of function: the elbow is flexed to 90 degrees with the wrist in a neutral,
slightly extended position

Pearls and Pitfalls

Adequate padding at the olecranon, ulnar styloid, and antecubital fossa prevents
skin breakdown. Physicians should avoid applying the edge of the casting tape over
the antecubital fossa, particularly with the initial layer. Long arm casts are used most
often in childhood because of the frequency of distal radial, ulnar, and distal humeral
fractures.

p. Double sugar-tong splint

This splint is used in acute management of elbow and forearm injuries, including
Colles fractures.
Application: physicians should start by placing a single sugar-tong splint (as
described above). A second sugar-tong splint is then applied, extending from the
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deltoid insertion distally around the 90-degree flexed elbow, and proximally to 3
inches short of the axilla.
The double sugar-tong splint is illustrated in figure 13 below.

Figure 13: An example of a double sugar-tong splint

Pearls and Pitfalls: the splint provides superior pronation and supination control, and
is preferable with complex or unstable fractures of the distal forearm and elbow.
Lower Extremity Splints and Casts

q. Posterior ankle splint (‘Post-Mold’)

This splint is used in the following situations:
 Acute, severe ankle sprain; non-displaced, isolated malleolar fractures.
 Acute foot fractures and soft tissue injuries.

Application: the splint extends from the plantar surface of the great toe or metatarsal
heads along the posterior lower leg and ends 2 inches distal to the fibular head to
avoid compression of the common peroneal nerve.

Pearls and Pitfalls: for efficient application, the patient should be placed in a prone
position with the knee and ankle flexed to 90 degrees.

r. Stirrup splint
This splint is used in the following situations:
 Acute ankle injuries.
 Non-displaced, isolated malleolar fractures.

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Application: the splint extends from the lateral mid-calf around the heel, and ends at
the medial mid-calf.
Position of function: the ankle is flexed to 90 degrees (neutral).

Pearls and Pitfalls

Stirrup and posterior ankle splints provide comparable ankle immobilisation.
Although the stirrup splint is adequate for short-term treatment of acute ankle
sprains, the evidence favours a functional approach to inversion ankle sprain
treatment with the use of a semi-rigid or soft lace-up brace. A bulky Jones splint is a
variation on the stirrup splint used acutely for more severe ankle injuries. The lower
extremity is wrapped with cotton batting and reinforced with a stirrup splint, providing
compression and immobilisation while allowing for considerable swelling.

s. Short leg cast

This cast is used for the definitive treatment of injuries to the ankle and foot.
Application: the cast begins at the metatarsal heads and ends 2 inches distal to the
fibular head. Additional padding is placed over bony prominences, including the
fibular head and both malleoli.
Position of function: the ankle is flexed to 90 degrees (neutral).

Pearls and Pitfalls

Weight-bearing recommendations are determined by the type and stability of the
injury and the patient's capacity and discomfort. Short leg walking casts are
adequate for non-displaced fibular and metatarsal fractures. Commercially produced
high-top walking boots are acceptable alternatives for injuries at low risk of
complication

t. Toe plate extensions

These extensions are used in the following situations:
 Toe immobilisation (comparable to a high-top walking boot or cast shoe).
 Distal metatarsal and phalangeal fractures, particularly of the great toe.

Application: a plate is made by extending the casting material beyond the distal toes,
prohibiting plantar flexion and limiting dorsi-flexion.
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The short leg cast with toe plate extension is illustrated in figure 14 below.

Figure 14: an example of a short leg cast with toe plate extension

Pearls and Pitfalls

The cast must be moulded to the medial longitudinal arch with the ankle at 90
degrees to allow for successful ambulation.

u. Posterior Knee Splint

This splint is used in the following situations:
 Stabilisation of acute soft tissue injuries (for example, quadriceps or patellar
tendon rupture, anterior cruciate ligament rupture),
 Patellar fracture or dislocation, and other traumatic lower extremity injuries,
particularly when a knee immobiliser is unavailable or unusable because of
swelling or the patient's size.

Application: the splint should start just below the gluteal crease and end just
proximal to the malleoli
Position of function: the knee is positioned in slight flexion.

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We hope you now have a better understanding of the first aid use of bandages and
splints. Before you continue on, complete the questions below as a way of reflecting
on what you have learnt.

Checkpoint Question 1
Q 1: Match the types of bandage in column 1 with the appropriate description in
column 2

Column 1 Column 2
1. Triangular bandage a. Treatment of lymphedema and venous ulcer
2. Long stretch Compression bandage b. Applied using an applicator
3. Tube bandages c. Secured with safety pins
4. Short stretch Compression bandage d. Have a very high resting pressure
e. Ankle is flexed to 90 degrees
Q 2. List four types of splints

Answers:
Q1
1. c
2. d
3. b
4. a

Q2
 Soft Splints
 Hard Splints
 Air or Vacuum Splint
 Traction Splints

3.6 Methods of Lifting and Transporting Casualties

The importance of proper transportation for a seriously injured person cannot be
overestimated. It is sometimes necessary to transport a patient some distance
before you can get a doctor. Improper or careless methods frequently increase the
severity of the injury and may even cause death. Don’t be hurried into moving an
injured person, and be sure that a thorough examination has been made and all
injuries are protected by proper dressing, splints, etc.
You are now going to look at lifting and transportation of casualties. In this section,
we will look at the following 6 methods of lifting and transporting casualties:

1. Using a stretcher
2. Vertical lift

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 3. Lifting with a strap
4. Translation lift
5. Rolling methods
6. Lifting a seated person

Let’s start by looking at how to lift and transport casualties using a stretcher.
3.6.1 Using a Stretcher

Procedure for using a stretcher.

a. Unfold the stretcher, secure the hinges and test it before carrying any
casualty.
b. Use a blanket since hypothermia is a major risk for a casualty.
c. Wrap the blanket around the casualty to avoid them losing any heat from
below (this is not necessary when the stretcher has a mattress, for example a
vacuum mattress, or in the case of an ambulance stretcher). For this purpose,
the blanket is placed before the lifting, and folded in a specific way:
 The blanket is laid so the diagonal is along the axis of the stretcher;
 The corners are put on the centre of the stretcher;
 The folded parts are then rolled towards the stretcher;
 The rolls are then put under the blanket, to prevent them from unrolling
spontaneously; the corners are sticking out so they can be pulled.

Figure 1 below gives an illustration of a stretcher with a blanket.

Figure 15: A stretcher with a blanket on top

You can also use scoop stretcher.

Scoop Stretcher

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The use of a scoop stretcher allows for secure lifting with only two team members
present, even in case of a spinal trauma. The use of this device is thus
recommended for most operations.

However, in many situations, it is the equipment that is lacking and not manpower.
Additionally, the scoop stretcher does not allow for positioning of the casualty’s legs
up or in a half-seated position. For these reasons, the other methods are considered.

3.6.2 Vertical Lift (Straddle Lift)

We are going to look at how to perform this technique with five and three members.

a) Vertical Lift with Five Team Members

Vertical lifting of a casualty with five team members and placement on the stretcher
head first, happens as follows:
a. First, the chief positions themselves with one knee down, one knee up, and
holds the head. They can hold it by sliding the finger under the head, the palm
placed on each side of the head or they can place one hand under the neck
and hold the occiput, with the other hand under the chin.
b. The first team member support themselves on the shoulder of another team
member, and steps over the casualty. Next, they put their hands under the
shoulders.
c. The second team member support themselves on the shoulder of another
team member, and step over the casualty. They place their hands under the
hip.
d. The third team member holds the ankles
e. The fourth team member pushes the stretcher.

Figure 16 below illustrates how to vertically lift a casualty onto a stretcher head first.

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Figure 16: An example of a five member team vertically lifting an emergency casualty onto
a stretcher head first.

Figure 17 below illustrates how to vertically lift a casualty onto a stretcher feet first

Figure 17: An example of a five member team vertically lifting an emergency casualty onto
a stretcher feet first.

The feet of the team members must be wide enough so that the stretcher can slide in
between them. If the chief uses the occipital-chin grip, the knee that is up is the knee
that corresponds with the side of the hand under the neck. This is because this arm
supports the heaviest weight, and can support itself on the knee.

Another method consists of placing the team members at both sides of the casualty
and holding the cloths. The cloths must be strong enough.
On the order of the chief, the casualty is lifted, the stretcher is pushed, and the
casualty is placed on the stretcher. During this procedure, the chief remains kneeling
(stable); the other team members lift pushing with their legs (arms stretched out,

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back kept straight). Then, the first and second team members pull back, supporting
themselves on the shoulder of a still standing member.

With this method, the movement of the casualty is minimal, and only happens
vertically.
When there is no room at the feet of the casualty for the stretcher, it must then be
placed on the side of the head. The chief must then kneel aside. If they use the
occipital-chin grip, the hand under the neck must be the closest to the casualty's feet
with the corresponding knee in the up position.

b) Vertical Lift with Three Team Members

When the casualty has no specific trauma, it is possible to progressively slide a long
spine board along the length of their body. One team member lifts a part of the body
(head, then shoulders, then hips), as the other member slides the board.

Figure 18: An example of a three member team vertical lifting an emergency casualty onto
a stretcher.

3.6.3 Lifting with a Strap

A handling strap can be used to help lift casualties in emergency situations. The
strap for this use should be 6 m long (20 ft.), at least 3 cm wide (1.2 in) to balance
out the weight and avoid any pain, and resist up to a weight of 150 kg (330 lb).

The Process of Lifting a Casualty using a Handling Strap

a. The strap is slid under the casualty. The flat profile of the strap allows it to
slide easily under the back and pelvis of the casualty without them.

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 b. This strap will form two handles. This gives the team member stationed at the
pelvis a better grip and allows them to maintain a vertical back
c. The strap crosses the middle of the casualty’s back, preventing the team
member at the head (lifting with four team members) or at the shoulders
(lifting with five team members) from positioning their arms between the
shoulder blades, and allowing them to maintain a vertical back when lifting.
Maintaining a vertical back when carrying a casualty is especially important in
the case of an overweight casualty.

Figure 19 below illustrates two ways of placing the handling strap across the
casualty’s body:

a. When the hollow of the back (just above the pelvis) is small (left picture), then
the strap is slid through the hollow until its middle point. Next, each end of the
strap is slid under the neck. After that, the two branches of the strap are slid
under the back, then the middle part is slid under the buttock.
b. When the hollow of the back is high enough (right picture), the strap is folded
in three, then slid in under the hollow of the back. The two ends of the strap
are slid towards the shoulders, and the middle part is slid under the buttocks.

Figure 19: How to lift a casualty using a strap lift

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Once the strap is successfully placed under the casualty, one end of the strap goes
on the shoulder of one team member and under their opposite armpit (it crosses the
back). It is then tied to the other end of the strap or held together by the team
member. A hand is also placed under the neck to support the head.

3.6.4 Translation Lift

The translation lift, or ‘Dutch’ lift, is used when it is not possible to push the stretcher:
There is no room for the stretcher at the feet or head of the casualty, or the stretcher
cannot slide/roll on the ground, or there are not enough first responders available. In
such a case, the stretcher is placed besides the casualty.
Figure 20 below illustrates a three person translation lift

Figure 20: Carrying a casualty using the translation lift with three first responders

When using the translation lift with four first responders, the following steps are
taken:
a. The first and second team members step over the casualty and the stretcher,
placing their feet on the farthest pole of the stretcher on each side.
b. The chief holds the closest pole with their knee on the ground, and the third
team member with their ankle.

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 c. The positions of the hands are the same as for the vertical lift with five first
responders.
d. The first in place is the chief. The stretcher is slid besides the casualty, with
the pole against the thigh of the chief. Then, the third team member takes
their place.
e. Once both extremities of the pole are blocked, the other team members can
step over the casualty (one by one, holding each other’s shoulders to avoid
falling) without any risk of rocking the stretcher.
f. On the order of the chief, the casualty is lifted and placed on the stretcher.

This method can be performed with only three first responders. In this case, the chief
plays the role of the first team member. They blocks the pole with their ankle, and
places one hand under the neck and the other under the back, between the shoulder
blades of the casualty. Only the team member positioned at the hips of the casualty
steps over the stretcher.

3.6.5 Rolling Methods (Log Roll)

Rolling methods are only used with a casualty who does not have an unstable
trauma. They are especially helpful for heavy casualties because rolling does not
require much effort, and the lifting itself is done in a more comfortable position (the
back of the first responders is vertical). They are also useful when the casualty is in a
very narrow place such as a pit or a ditch because the rolling allows sliding of the
lifting device (board, flexible stretcher, halves of the scoop stretcher).

Rolling methods help position the casualty on their side, which makes it possible:
 To put a long spine board against his/her back, then to roll back the casualty
on his/her back;
 To slide a folded flexible stretcher (or a blanket); the casualty is then rolled on
the other side to unfold the flexible stretcher.

The casualty can then be lifted using the handles of the long spine board or the
flexible stretcher (or by holding the rolled sides of a blanket), and placed on a
stretcher.

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The rolling method is usually carried out by a four member team, using the following
steps:
a. The chief kneels at the head, in the axis of the casualty, and holds the head.
b. The first team member kneels beside the casualty, and holds the opposite
shoulder and the opposite hip.
c. The second team member kneels at the feet, in the axis of the victim, and
holds the ankles.
d. At the order of the chief, the casualty is rolled towards the first team member,
and the fourth team member puts the board or the flexible stretcher in place.

This method can also be performed by two first responders. In this case: the chief
plays the role of the first team member, and the second team member deals with the
board (neither the head nor the ankles are gripped). This is rather traumatic for the
casualty, but can be used when there is no suspicion of trauma, either in emergency
(for example to transport a cardiac arrest when advanced life support cannot be
performed on site), or when the first responders are lacking.
Figure 21 and 22 below illustrate the basic roll and lift method of lifting casualties.

Figure21: An example of the rolling method (log roll) used when lifting casualties.

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Figure 22: The roll-and-lift method using a long spine board

The use of a flexible stretcher was inspired by the method used to change the sheets
of immobile patients in the hospital. The following steps are taken when using a
flexible stretcher:
a. The flexible stretcher is placed beside the casualty, and a sheet is placed on
it.
b. The third of the stretcher that is the closest to the casualty is folded onto the
middle third.
c. The casualty is first rolled away from the stretcher, and the stretcher is slid
against the back of the casualty.
d. The casualty is put on their back and rolled onto the other side and the
stretcher and the sheet are unfolded.
e. The casualty is wrapped using the sheet, and can be lifted with the handles of
the flexible stretcher.

Figure 23 below illustrates the roll and lift method using a flexible stretcher.

Figure 23: The roll- and-lift method using a flexible stretcher

It is also possible to use a manual roll-and-lift method, also known as ‘spoon’ lifting
(relevage à la cuiller in French), with three people. The steps taken for this method
are as follows:

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 a. The first responders line up along one side of the casualty. The first
responder’s knee that is closest to the head of the casualty is lifted and the
other knee is placed on the ground.
b. The chief is positioned at the head of the casualty. They place one arm under
the neck and reach the opposite shoulder and then place the other arm under
the back.
c. The first team member is positioned beside the pelvis. They place one arm
under the back and the other arm under the thighs.
d. The third team member supports the legs.
e. At the order of the chief, the casualty is lifted and placed on the lifted knees of
the first responders.
f. Next, the casualty is flattened against their chests, after which the first
responders stand up.
g. They move towards the stretcher where they place one knee on the ground
(the closest to the casualty's feet), lay the casualty on their back, and move
the casualty from their knees to the stretcher. For this last movement,
additional first responders can be placed on opposite sides of the stretcher to
help the landing.

Spoon lifting can also be used for to move casualties in emergency situations when
spine trauma is suspected. For example, when a casualty is unconscious and there
is a threat of flooding in their immediate environment.

Figure 24 below illustrates the manual roll and lift method.

Figure 24: The manual roll-and-lift method ( ‘spoon lifting’), with three first responders.

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3.6.6 Lifting a Seated Casualty

In some emergency situations, it may be necessary to lift a seated or half seated

casualty. The seating position is adapted for a conscious person with a chest trauma
or respiratory difficulties.

When lifting a seated casualty, the following steps should be taken:

a. Two team members would be positioned on either side of the casualty.
b. Next, they would place one hand under the buttock and their other hand under
the opposite armpit of casualty.
c. The casualty would then place their arms around the necks of the two team
members.
d. A third team member would then lift the legs as usual, and a fourth team
member would push the stretcher.

When a heart problem is suspected, the casualty should not lift their arms. In this
case, a short strap (4 m, 13 ft.) can be used as follows:
a. One end of the strap is slid under the buttock and the other end of the strap
goes under each armpit (and thus crosses the back of the casualty) of the
casualty.
b. The two ends of the strap are tied to form a ring.
c. The team members use this ring as handles, keeping in mind that the head of
the casualty is not held.

The use of a long strap (6 m, 20 ft.) allows for the lifting of a casualty with only three
team members. The following steps are taken:

a. The short end of the strap is slid under the buttocks of the casualty.
b. A team members is placed over the legs of the casualty, facing them. The
long end of the strap goes under the team member's armpit and over their
opposite shoulder.
c. This strap is then passed under the armpits of the casualty, and again under
the team member's shoulder.

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 d. Both ends of the strap are tied or held together by the team member. This
creates a cross on the back of the first responder. The team member can then
support the full weight of the top of the casualty's body while keeping a
vertical back.
e. The long extremity goes on the team member's shoulder and under his/hers
opposite armpit; then this extremity then goes under the armpits of the
casualty, and again on the team member's shoulder.
f. With this possibility, all the weight is on one shoulder; it can be interesting
when the first responder has a loose foothold on one side, or has a problem
with one shoulder but cannot be replaced by another team member.

Figure 25 below illustrates the process of lifting a seated casualty using a long strap.

Figure 25: An example of how to lift a seated casualty using a long strap

When a casualty is seated on a chair or the seated position (with legs down) is
possible (that is, no problem of blood circulation), and the chair has fixed legs and
cannot be folded, then the chair itself can be used for the transport. Otherwise, the
chair can be replaced by a wheelchair or a stretcher.

The following steps should be taken when transferring a seated casualty to a

wheelchair or stretcher:
a. Two team members position themselves on either side of the casualty as
usual.

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 b. They would then lift the casualty, allowing a third team member to remove the
chair.
c. The third team member would then position the wheelchair under the
casualty, or deal with the causality's legs as a fourth team member pushes the
stretcher.

We hope you now have a better understanding of the methods you can use when
lifting casualties in emergency situations. Before you continue on, answer the
question below as a way of reflecting on what you have learnt.

CHECKPOINT QUESTION NO. 2

For each question below, circle the most appropriate answer.

Q1. The manual roll and lift method of transporting casualties is also known as
a. Roll lifting
b. Spoon lifting
c. Translation lifting
d. Vertical lifting

Q2. The scoop stretcher lifting technique uses

a. 3 people
b. 4 people
c. 6 people
d. 2 people

Answers:
Q1. B
Q2. D

3.7 First Aid Management of Medical Emergencies

In this section, we shall discuss the first aid management of various medical
emergencies. These are
 asphyxia
 cardiac arrest
 haemorrhage
 shock
 unconsciousness
 head injuries
 fractures, sprains and dislocations

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  spinal and chest injuries
 drowning
 wounds
 burns and scalds
 bites and stings
 fits and infantile convulsions
 fainting and heat exhaustion
 ward accidents
 ingesting corrosives, strong acids and alkaline substances

3.7.1. Asphyxia

What is asphyxia?

Asphyxia is a deficiency of oxygen in the blood and an increase in carbon dioxide in

the blood and tissues that leads to breathing problems.

Causes of Asphyxia
What causes asphyxia? Think about this for 2 minutes and complete the activity
below.

Activity 3.2
Write down in your notebook, at least two causes of asphyxia.

Well done! Compare your answers with the causes listed in the section below.
Asphyxia can occur when there is an interruption in the normal exchange of oxygen
and carbon dioxide between the lungs and outside air.

Common causes of asphyxia include:

 Presence of a foreign body in the air passages
 Drowning
 Electrical shock

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  Inhalation of smoke and poisonous gasses
 Trauma or disease to the lungs or air passages.

The common thread in all these causes is interference with the body’s gaseous
exchange process which leads to asphyxia.

Clinical Features
Patients experiencing asphyxia may present with the following clinical features:
 Irregular respirations
 Complete absence of breathing
 Restlessness
 Pallor
 Tachycardia

First Aid Management

These are the steps to take when managing a person with asphyxia.
a. Ensure that the patient’s airway is clear. To achieve this, you must place them
flat on their back with their head turned to the side. Vomitus or other debris
should be scooped out of the mouth. Remove false teeth as well if any.
b. As a first aider kneel down besides the patient’s head and ensure that the
patient is lying flat. Places one hand under the victim’s neck and the other
under the lower jaw. The head and the neck is extended backward.

3.7.2 Cardiac Arrest

Cardiac arrest (also known as cardiopulmonary arrest or circulatory arrest) is

the cessation of normal circulation of the blood due to failure of the heart to contract
effectively. When the heart stops pumping or is pumping in a manner that little or no
blood is circulating then the patient, is said to be clinically dead and biological death
may follow about three minutes later.

Causes of Cardiac Arrest

What causes cardiac arrest? Think about this for 2 minutes and then complete the
activity below.

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 Activity 3.3
Write down in your notebook, at least three causes of cardiac
arrest.

Well done! Compare your answers with the causes listed in the section below.

The following are the causes of cardiac arrest:

 Airway obstruction
 Severe spasms to the trachea or bronchus
 Suffocation, for example by a plastic bag
 Compression of the neck
 Compression of the thoracic cavity
 Damage to the nervous system controlling the respiratory system
 Myocardial infarction
 Failure of the cardiac conducting system
 Cardiogenic shock.
You will learn more about these conditions in the course on surgery or medicine. All
you need to know is that these conditions lead to cessation of normal circulation of
the blood due to failure of the heart to contract effectively.

Clinical Features
Patients experiencing cardiac arrest may present with the following clinical features:
 The person is unconscious often occurring as a sudden collapse
 You cannot palpate the pulse
 Apnoea
 Dilating/dilated pupils
 Cyanosis, which is blue discoloration of the skin and mucous membranes due
inadequate oxygen supply

First Aid Management

These are the steps to take when managing a person with cardiac arrest. If other
people are within reach, shout for help while preparing to treat the patient.
a. Lay the patient flat on a firm hard surface and with a closed fist give a sharp
bang on the lower third of the sternum (blow of life). This may be enough to

86
 restart the heart beat without further action. This procedure should only be
used on adults.
b. Check the pulse again. If still absent, clear the airway before commencing
external cardiac massage and artificial respiration at a ratio of 1 breathe to
every 6 compressions. The patient’s lungs should be inflated before external
cardiac massage.
c. Call emergency medical help quickly by dialing 999.

3.7.3 Haemorrhage

Haemorrhage or bleeding is a loss of blood from a ruptured blood vessel, either

inside or outside the body.

As mentioned in the definition, there are two types of bleeding:

a. External bleeding: blood escapes from the circulation to the outside of the
body. You can usually see and recognise it.
b. Internal bleeding: blood escapes from circulation but is inside the body.

a) External Bleeding
This is bleeding that is visible, that is, blood can be seen.
External bleeding is recognisable and usually associated with open injury. There are
many different types of wounds and open injuries. They can be a break in the
continuity of the skin, such as abrasions, lacerations, excoriation, incision, puncture
wounds, and gunshot wounds.
Signs and Symptoms
The presence of blood is an easy way to spot external bleeding. In large wounds, it
may be challenging to locate the source of bleeding. The rule in wound management
is when an injury involves more than 5 cups of blood; then the wound is life-
threatening.
Other common signs of external bleeding include:

 Visible wound, with or without an embedded foreign object

 Pain from the skin surface
 Loss of normal function in the site of injury
 Pale, cold, and clammy skin
 Fast heart rate
 Low blood pressure
 Dizziness or lightheadedness
 Loss of consciousness

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First Aid Management
These are the steps to take when managing a person with external bleeding:

a. Lay the casualty down.

b. Apply direct pressure to the site of bleeding.
c. Raise and rest the injured part when possible.
d. Loosen tight clothing.
e. Give nothing by mouth.
f. Seek medical aid urgently.

This is how you can apply direct pressure:

a. Apply direct pressure to the wound with your fingers or hand.
b. As soon as possible, place a clean dressing over the wound. Apply a bulky
pad extending beyond the edges of the wound, and firmly bandage. If
bleeding continues, leave the dressing in place and relocate the pad.
c. Do not disturb pads or bandages once bleeding is controlled.

Uncontrolled Bleeding
Uncontrolled bleeding is when you are not able to control bleeding even after
applying direct pressure. If severe bleeding cannot be controlled by direct pressure,
it may be necessary to apply pressure to the pressure points. These are found on
the main artery above the wound. When bleeding has been controlled, remove
pressure from the point and reapply direct pressure to the wound. Occasionally, in
major limb injuries such as partial amputations and shark attacks, severe bleeding
cannot be controlled by direct pressure. Only then, it may be necessary for you to
resort to the application of a constrictive bandage above the elbow or knee.

When using a constrictive bandage do the following:

a. Select a strip of firm cloth, at least 7.5 centimetres (3 inches) wide and about
75 centimetres (30 inches) long. This may be improvised from clothing or a
narrow folded triangular bandage.
b. Bind the cloth strip firmly around the injured limb above the bleeding point
until a pulse can no longer be felt beyond the constrictive bandage and
bleeding is controlled. Tie firmly.

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 c. Note the time of application. After 30 minutes, release the bandage and check
for bleeding. If there is no bleeding, remove it .If bleeding recommences,
apply direct pressure. If this is unsuccessful, reapply the constrictive bandage,
and recheck every 30 minutes.
d. Ensure that the bandage is clearly visible and inform medical aid of the
location and time of its application.

b) Internal Bleeding
This is blood that escapes from circulation inside the body.

Signs and Symptoms

You may see evidence of internal bleeding from some organs. For example:
 Coughing up red frothy blood if the bleeding organ is in the chest.
 Vomiting blood the colour of coffee grounds or bright red. The blood may be
mixed with food.
 Passing of faeces with a black, tarry appearance if the blood has gone
through digestion process.
 Passing of faeces that is red in colour if the bleeding is in the anal area.
 Passing urine which has a red or smoky appearance if the blood is coming
from organs in the urinary system.

You can suspect concealed bleeding within the abdomen when there is:
 Abdominal pain
 Abdominal tenderness
 Rigidity of abdominal muscles.

For you to identify abdominal bleeding, you need to palpate the patient. Remember
that you looked at palpation under physical examination.

Internal bleeding can also be accompanied by any of the following symptoms and
signs:
 Faintness or dizziness because the amount of blood circulating has reduced
because of bleeding.
 Patient is restless

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  Patient feels like vomiting
 Patient feels thirsty
 The pulse is weak and rapid
 The skin feels cold and clammy
 The breathing is rapid and there is gasping as the patient is breathing as if the
air is not enough.
 Pallor
 The patient also usually sweats.
As mentioned earlier on, these signs and symptom are as a result of a reduction in
the amount of blood circulating because of bleeding.

First Aid Management

These are the steps to take when managing a person with internal bleeding.
a. Lay the casualty down
b. Raise the legs or bend the knees
c. Loosen tight clothing
d. Seek medical aid urgently
e. Give nothing by mouth
f. Reassure the casualty

Since bleeding can lead to shock, let us look at shock in the next section.

3.7.4 Shock

What is shock?

Shock is a serious medical condition in which the body is not getting enough blood
flow, therefore tissue perfusion becomes insufficient to meet demand for oxygen and
nutrients.

Causes of Shock
What causes shock? Think about this for 2 minutes and complete the activity below.

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 Activity 3.4
Write down in your notebook, at least two causes of shock.

Good attempt! Compare your answers with the causes listed below.

Shock can be caused by the following:

 Haemorrhage due to severe injury.
 Loss of body fluids other than blood for example vomiting, diarrhoea burns.
 Infection
 Poisoning by chemicals, gases, alcohol, or drugs.
 Lack of oxygen caused by obstruction of air passages or injury to the
respiratory system.

Clinical Features
In the early stages of shock, the body compensates for decreased blood flow by
constricting blood vessels in the skin, soft tissues and skeletal muscles. The
following signs may result:
 Low blood pressure.
 Altered mental state, including reduced alertness and awareness, confusion,
and sleepiness.
 Cold, moist skin. Hands and feet may be blue or pale.
 Weak or rapid pulse.
 Rapid breathing and hyperventilation.
 Decreased urine output.
In late stages of shock, the patient becomes apathetic (not interested in anything)
and relatively unresponsive. The patient’s eyes are sunken, with a vacant expression
and pupils may be widely dilated.

First Aid Management

Treatment for shock in first aid conditions can be managed by the acronym WARTS
 W- Warmth
 A-ABC's (Airway, Breathing, Circulation or CPR)
 R-Rest and reassurance

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  T-Treatment (treat the cause of shock)
 S-Semi-prone position, which is the same thing as recovery position

Figure 26: Casualty with elevated lower limbs

The first aid treatment of shock includes the following steps:

a. Immediately place the patient in a comfortable position if they are conscious
b. If you are alone, call for help. If not, send someone to call for help and have
someone stay with the victim.
c. Ensure airway patency and assess breathing. If possible, place the patient in
the recovery position.
d. Apply direct pressure to the wound if there is any bleeding.
e. Cover the patient with a blanket or jacket that is not too thick, to prevent
vasodilation.
f. Do not give them a drink but you can moisten their lips if requested.
g. If you notice the legs are uninjured, elevate them 20–30 cm (Trendelenburg
position).
h. Reassure the patient, as they will be very anxious, frightened and possibly
nauseated.
i. Prepare for cardiopulmonary resuscitation (CPR).
j. Once you've cared for the patient's immediate needs, gather a focused
history: ‘What happened?’ ‘Do you have any medical problems?’ ‘Do you take
any medications?’ ‘Do you have any allergies to medications?’ Record this
information if possible. The patient may lose consciousness, and this
potentially valuable information may be lost.

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 k. Provide the gathered information to the ambulance personnel when they
arrive

Please note that the management of shock requires immediate intervention, even
before a diagnosis is made. Re-establishing perfusion to the organs is the primary
goal through restoring and maintaining the blood circulating volume, ensuring
oxygenation and blood pressure are adequate, achieving and maintaining effective
cardiac function, and preventing complications.

Now that you have looked at the management of shock, let us discuss the
management of unconsciousness.

3.7.5 Unconsciousness

Unconsciousness is when a person is unable to respond to people and activities.

Often, this is called a coma or being in a comatose state. You must treat
unconsciousness or any other SUDDEN change in mental status as a medical
emergency.

Causes of Unconsciousness
 Unconsciousness can be caused by nearly any major illness or injury, as well
as substance abuse and alcohol use.
 Brief unconsciousness (or fainting) is often caused by dehydration, low blood
sugar, or temporary low blood pressure. However, it can also be caused by
serious heart or nervous system problems. The doctor will determine if you
need tests.
 Other causes of fainting include straining during a bowel movement, coughing
very hard, or breathing very fast (hyperventilating).

Symptoms of Unconsciousness

Activity 3.5
Write down in your notebook, at least three symptoms of
unconsciousness.

Well done! Compare your answers with the symptoms listed below.

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The person will be unresponsive (does not respond to activity, touch, sound, or other
stimulation).
The following symptoms may occur after a person has been unconscious:
 Confusion
 Drowsiness
 Headache
 Inability to speak or move parts of their body
 Light-headedness
 Loss of bowel or bladder control (incontinence)
 Rapid heartbeat (palpitations)
 Stupor

First Aid Management

These are the steps to take when managing a person who is unconscious:

a. Call for help

b. Check the person's airway, breathing, and pulse frequently. If necessary,
begin rescue breathing and cardio pulmonary resuscitation.
c. If the person is breathing and lying on their back, and you do not think there is
a spinal injury, carefully roll the person toward you onto their side. Bend the
top leg so both hip and knee are at right angles. Gently tilt the head back to
keep the airway open. If breathing or pulse stops at any time, roll the person
on to their back and begin cardiopulmonary resuscitation.
d. If you think there is a spinal injury, leave the person where you found them (as
long as breathing continues). If the person vomits, roll the entire body in one
movement to the side. Support the neck and back to keep the head and body
in the same position while you roll.
e. Keep the person warm until medical help starts.
f. If you see a person fainting, try to prevent a fall. Lay the person flat on the
floor and raise the feet about 12 inches.
g. If fainting is likely due to low blood sugar, give the person something sweet to
eat or drink when they become conscious.

DO NOT do any of the following when managing an unconscious person:

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  DO NOT give an unconscious person any food or drink.
 DO NOT leave the person alone.
 DO NOT place a pillow under the head of an unconscious person.
 DO NOT slap an unconscious person's face or splash water on the face to try
to revive them.

You have now concluded the management of an unconscious person. Let us now
look at head injury.

3.7.6 Head Injury

Head injury is trauma to the head that may lead to injury of the scalp, skull, or brain.
These cases really need quick action (first aid) to perform basic life support and save
the victim's life. So it means that you need to act quickly.
Figure 27 below gives an example of a person with head injury.

Figure 27: Head injury

Causes of Head Injury

The following are the most common causes of head injury;
 Traffic accidents
 Falls where a person hits the head either on an object or bear land
 Physical assault where an object is used to hit a person.
 Accidents at home, work, outdoors, or while playing sports.
In all these instances there is trauma to the head that may lead to injury of the scalp,
skull, or brain.

Clinical Features

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Head injuries may result into minor bump on the skull to serious brain injury, so it is
extremely important for you to pay close attention to the following symptoms:
 Loss of consciousness
 Abnormal breathing (interruption of breathing)
 Bleeding or clear fluid from the nose, ear, or mouth
 Vomiting more than two to three times

If you find the victim of head injury with any of the symptom above, it's mean the
victim is having serious head trauma and will require professional medical attention
as the first aid action. Call for emergency medical services (EMS) immediately by
dialing 999.

First Aid Management

Before the EMS team arrives, perform first aid as follows:

a. Stop any bleeding by firmly pressing a clean cloth to the wound.
b. Check the person's airway, breathing, and circulation. If necessary, begin
rescue breathing and cardiopulmonary resuscitation. If possible, place the
victim in a quiet area. If the injury is serious, be careful not to move the
person's head.
c. Do not leave the victim unattended to.
d. If the victim is vomiting, roll them onto their side to prevent them from
chocking. When rolling them, keep the head, neck, and body aligned.
e. Do not apply direct pressure to the wound area if there is suspected fracture
of skull

We hope you now understand how to manage a person with a head injury. Next, we
will look at how to manage fractures, sprains and dislocation.

3.7.7 Fractures, Sprains and Dislocation

a) Fractures
A fracture is a break in the bone, generally caused by trauma, twisting, or weakened
bone structure due to disease.

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Types of Fractures
There are two types of fractures.
 Simple fracture (no wound around the fractured area).
 Compound fracture (underlying skin has been broken or damaged).

Clinical Features
A person with a fracture will present with the following features:
 Pain: the patient usually complains of pain and may give history of hearing a
snap of the bone.
 Person is unable to move the broken limb. This may be due to pain or loss of
leverage.
 Deformity and shortening: the portion of the limb below the fracture is usually
found to be out of line with the portion above the fracture and is obviously in
an unnatural position.
 Crepitus: this is the sensation of grating caused by the broken ends of the
bone being rubbed against each other.
 Abnormal mobility of the bone at the site of the fracture. There may be
movement at the point where the break has occurred.
 Other signs: swelling, dislocation of the injured part, and tenderness to touch.

First Aid Management

These are the steps to take when managing a person with a fracture:
a. Control the bleeding.
b. Care for shock if patient is in shock.
c. Splint affected area to prevent further movement (without causing further pain
to victim). (Recall what you learnt about splinting from section 3.5.2)
d. Applying cold packs (as shown in figure 28 below) may help reduce pain and
swelling.

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Figure 28: Cold pack application in the first aid management of a fracture

e. Call the emergency medical services (EMS) or ambulance by dialing 999.

f. If the victim is unresponsive, you need to check their breathing and heartbeat.
g. Begin cardiopulmonary resuscitation (CPR) if there is no respiration or
heartbeat until emergency personnel arrive.

b) Sprain
A sprain is an injury to the soft tissue surrounding joints, usually as a result of forcing
a limb beyond the normal range of a joint. As a result, the ligaments, muscles,
tendons and blood vessels are stretched or torn. Ankles, fingers, wrists and knees
are most commonly sprained.

Clinical Features
A person with a sprain may present with the following clinical features:
 Swelling on the affected part.
 The affected part is tender touch.
 Pain upon motion.

First Aid Management

a. If the victim’s ankle or knee is affected, do not allow them to walk as this may
worsen the situation.
b. Loosen or remove the victim’s shoes.

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 c. In the case of a mild sprain, keep the injured part raised for at least for 24 hrs.
(Do not soak in hot water).
d. Apply a cold, wet pack or place a small bag of crushed ice on the affected
area, over a thin towel to protect the victim’s skin.

c) Dislocation
Dislocation is the displacement of a bone end from the joint, particularly at the
shoulder, elbow, fingers or thumb.

Causes of Dislocation
Dislocation may result from a fall or direct blow. Unless given proper care, a
dislocation may occur repeatedly.

Clinical Features
A person with a dislocation may present with the following clinical features:
 Swelling on the affected part.
 Obvious deformity because of the displacement of the bone end of the joint.
 Pain upon movement.
 Tenderness to touch.
 Affected bone will be out of place.

First Aid Management

First aid management is similar to that of a closed fracture.
a. Splint and immobilise the joint in its original position.
b. Apply a sling if appropriate. Elevate the affected part, if a limb is involved.
c. Seek medical attention promptly.
d. Never attempt to reduce a dislocation or to correct any deformity near a joint,
since extensive tearing of the joint capsule often occurs.

In the next section, we will discuss spinal and chest injuries. Before you continue on,
answer the questions below as a way of reflecting on what you have learnt.

Checkpoint Question 3
For each of the following questions, circle the most appropriate answer.
1. Which of the following is a clinical feature of asphyxia?

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 a. Bradycardia
b. Jaundice
c. Restlessness
d. Regular respirations
2. Which of the following terms best describes the following statement ‘the cessation of
normal circulation of blood due to failure of the heart to contract’.
a. Haemorrhage
b. Shock
c. Cardiac arrest
d. Asphyxia
3. A break in the bone is known as…….
a. Wound
b. Fracture
c. Burns
d. Scalds
4. An injury to the soft tissues surrounding the joints is called;
a. Fracture
b. Sprain
c. Wound
d. Head injury
5. List three (3) causes of shock

Answers:
1. C; 2.C; 3.B; 4.B
Q5:
 Haemorrhage due to severe injury
 Loss of body fluids other than blood for example vomiting, diarrhoea, burns
 Infection
 Poisoning by chemicals, gases, alcohol or drugs
 Lack of oxygen caused by obstruction of air passages or injury to the respiratory
system

3.7.8 Spinal and Chest Injuries

a) Spinal Injury

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This is injury to the spine which may be due to road traffic accidents or trauma to the
spine.

Clinical Features

Activity 3.6
Write down in your notebook, at least three clinical features of a
person with spinal injury.

Good attempt! Compare your answers with the clinical features listed below.

A person with a spinal injury may present with the following clinical features:
 Mental confusion (such as paranoia or euphoria)
 Dizziness
 Head, neck or back pain
 Paralysis
 Any fall where the head or neck has fallen more than two meters (just over
head height on an average male)
 Cerebrospinal fluid in the nose or ears
 Resistance to moving the head
 Pupils which are not equal and reactive to light
 Head or back injury
 Priapism

First Aid Management

a. The victim should not be moved unless absolutely necessary.
b. Without moving the victim, check if the victim is breathing.
c. If they are not, CPR must be initiated.
d. The victim must be rolled while attempting to minimize movement of the
spine.
e. If the victim is breathing, immobilise their spine in the position found. The
easiest way to immobilise the spine in the position found is sandbagging. This
technique involves packing towels, clothing, or bags of sand among others,
around the victim's head such that it is immobilised.

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 f. Be sure to leave their face accessible, since you'll need to monitor their
breathing.
g. Refer the victim to a health institution immediately.

If you must roll the victim over to begin CPR, take great care to keep their spine
immobilised. You may want to recruit bystanders to help you. Hands-on training is
the only way to learn the various techniques which are appropriate to use in this
situation.

Let us now look at chest injuries.

b) Chest Injuries
Chest injuries can be inherently serious, as this area of the body houses many
critical organs, such as the heart, lungs, and many blood vessels. Most chest trauma
injuries should receive immediate professional medical attention. Always call for an
ambulance for any potentially serious chest injuries.

Recall what you have learnt about the chest from the course on Anatomy and
Physiology.

There are numerous types of possible thoracic injuries. Although some require
further diagnostic testing and specialised surgical treatment after arriving at the
hospital, several injuries require recognition and immediate treatment in the pre-
hospital setting. These injuries are: closed pneumothorax, open pneumothorax,
sucking chest wound, tension pneumothorax and flail chest.
These conditions are covered in full in the Surgery and Surgical Nursing I & II
courses. In this section, the focus will be on the first aid management of these
conditions.

Assessment & Treatment

The first and most important step in the management of the chest trauma is
maintaining a high level of suspicion.
Suspect the involvement of other critical organs and the conditions that can result
thereafter. For example:

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  Pneumothorax: closed pneumothorax, open pneumothorax, sucking chest
wound, tension pneumothorax and flail chest.
 Haemothorax.
 Trauma to the heart and major blood vessels.
 Trauma to the Oesophagus.

Signs and Symptoms

The classic signs and symptoms are:
 Presence of dilated neck veins.
 Dusky or blue lips or nail beds.
 May cough up blood.
 Crackling feeling upon touching victim's skin (sounds and feels like ‘Rice
Krispies’).
 Difficulties in breathing.
 Shallow breathing.
 Tenderness at the injury site.
 Tracheal deviation.
 Deformity & bruising of chest.
 Pain upon movement / deep breathing / coughing.
 Subcutaneous emphysema.
 Unilateral breath sounds absent.
 Tachycardia and hypotension.

Patients with a pneumothorax, regardless of the type, will present with respiratory
distress, including dyspnea, tachypnea and tachycardia.
Should these findings be present, the chest must be decompressed immediately to
prevent circulatory collapse. A simple closed pneumothorax requires no immediate
treatment and is often not discovered in the pre-hospital setting.
Figure 29 below gives an illustration of a chest injury.

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Figure 30: An example of a chest injury

First Aid Management

The first aid steps given below are for all chest injuries. There are specific measures
for individual injuries which will be covered in Surgery and Surgical Nursing course.
The following steps are used in the first aid management of a person with a chest
injury:
a. Assess ABCs and intervene as necessary.
b. Call for an ambulance.
c. Assist the victim into a comfortable position (typically seated upright, to avoid
fighting gravity).
d. Conduct a secondary survey.
e. Monitor victim's condition carefully.
f. Be vigilant, keep alert for any changes.
g. If a flail segment is suspected, tightly secure a bulky dressing (such as a
tightly folded hand towel) to help stabilise the injury.
h. Do not remove any embedded objects.
i. Lateral positioning: victim's injured side down.
j. Treat for shock.
k. Monitor vitals carefully.

Remember, trauma is a surgical emergency and it is fixed in the operating room.

Advanced medical care and immediate extraction and evacuation to a Trauma
Centre is strongly advised.

Next, we will look at drowning.

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3.7.9 Drowning

Activity 3.7
In your own words, write down the definition for drowning in your
notebook.

Good attempt! Compare your answer with the definition given below.

Drowning is the result of complete immersion of the nose and mouth in water (or any
other liquid). Water enters the windpipe and lungs, clogging the lungs completely
and making breathing extremely difficult.

First Aid Management

The aim of first aid is to drain out water (or other matter) from lungs and to give
artificial respiration.

Take the following steps in the case of drowning:

a. Act quickly. Remove seaweed, mud and nay other debris from the nose and
throat. Start artificial ventilation immediately. This is possible even when the
casualty is in water.
b. Turn the victim face down, with head to one side and arms stretched beyond
the head. Infants or children can be held upside down for a short period to
drain water.
c. Raise the middle part of the body with your hands round the belly. This is to
cause water to drain out of the lungs.
d. Give artificial respiration until breathing returns to normal. This may go on for
as long as two hours.
e. Remove wet clothing because wet clothes will make the victim feel cold.
f. Keep the body warm to prevent subnormal temperature and cover with
blankets.
g. When victim becomes conscious, give hot drinks such as coffee or tea to
make them feel warm.
h. Do not allow them to sit up.
i. After doing the above, transfer the victim quickly to hospital as a stretcher
case.

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Let us now look at wounds.

3.7.10 Wounds

A wound is a cut or break in the continuity of any tissue caused by injury or

operation.
Wound healing is the replacement of dead tissue (necrotic) by living tissue.

Types of Wounds
a. Lacerated wound: this type of injury has rough or jagged edges. For example,
injuries sustained in a road traffic accident, barbed wire injury among others.
b. Incisional wounds: these are types of injuries made by sharp objects. They
have edges that are evenly separated. For example, wounds made by
surgeons during surgery.
c. Punctured wounds: these are wounds that are caused by sharp pointed
objects causing a small opening through the skin. These are commonly
caused by objects such as nails, knives, gun shots among others. They
appear small superficially but involving deeper structures such as nerves,
blood vessels or viscera which may be damaged allowing contamination in
deeper tissues.
d. Contused wounds: these are a type of wound that involves superficial injuries
without damage to the skin surface. They are commonly caused by blunt
surface forces and are characterised by a considerable soft pad. They are
commonly known causes of haematomas.
e. Poisoned wounds: these wounds involve direct contamination by the source
of the injury such as snake bites, insect bites, dog bites especially where
rabies organisms exist.
f. Concussions: these are a type of wound that result from vigorous shaking
such as the severe shaking of the head causing brain function derangement
without structural damage.
g. Abrasions: these are wounds that result from rubbing a body tissue especially
the skin against a rough surface leading to loss of superficial tissue due to
friction. These are characteristically painful and superficial.

Wounds can also be classified surgically as follows:

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 a. Contaminated Wounds
These are wounds which are exposed to excessive amounts of bacteria. These
wounds have a higher risk of infection. For example, unprepared colon surgery, dirty
laceration among others.
b. Infected Wounds
These are wounds that have infected material in them. They usually have pus or
slough on their surfaces. Common infecting organisms include streptococci,
staphylococci among others.
c. Clean Wounds
These are wounds that have been rendered clean by the use of disinfectants such
as Savlon, povidone iodine, methylated spirit, among others.
d. Debrided Wounds
These are wounds whose top infected (necrotic tissue and pus) tissue has been
removed surgically by a process known as sloughectomy or debridement.
First Aid Management of Wounds
A wound is any damage or break in the surface of the skin.
Applying appropriate first aid to a wound can speed up the healing process and
reduce the risk of infection.
Wounds including minor cuts, lacerations, bites and abrasions can be treated with
first aid.
1. Control bleeding
Use a clean towel to apply light pressure to the area until bleeding stops (this may
take a few minutes). Be aware that some medicines (e.g. aspirin and warfarin) will
affect bleeding, and may need pressure to be applied for a longer period of time.
2. Wash your hands well
Prior to cleaning or dressing the wound, ensure your hands are washed to prevent
contamination and infection of the wound.
3. Rinse the wound
Gently rinse the wound with clean, lukewarm water to cleanse and remove any
fragments of dirt, e.g. gravel, as this will reduce the risk of infection.
4. Dry the wound
Gently pat dry the surrounding skin with a clean pad or towel.
5. Replace any skin flaps if possible

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If there is a skin flap and it is still attached, gently reposition the skin flap back over
the wound as much as possible using a moist cotton bud or pad.
6. Cover the wound
Use a non-stick or gentle dressing and lightly bandage in place; try to avoid using
tape on fragile skin to prevent further trauma on dressing removal.
7. Seek help
Contact your GP, nurse or pharmacist as soon as possible for further treatment and
advice to ensure the wound heals quickly.
8. Manage pain
Wounds can be painful, so consider pain relief while the wound heals.

Assessment
Determining when and how the wound occurred is important because a treatment
delay exceeding 3 hours increase infection risk. Using aseptic techniques, the
clinician inspects the wound to determine the extent of damage to underlying
structures. Sensory, motor, and vascular functions are evaluated for changes that
might indicate complications.

The area around the wound should be kept clean. Hair around the wound should be
removed especially if it is anticipated that it will interfere with wound healing and
closure. The wound is irrigated with normal saline solution or polymer to remove
surface dirt. Devitalised tissue and foreign matter are removed because these
impede wound healing and may encourage infection. Any small bleeding vessels are
clamped and tied. After wound treatment, a non-adhesive dressing is commonly
applied to protect the wound.

Antibacterial agents such as povidone iodine (Betadine) or hydrogen peroxide are

used on the wound but these should be allowed deeper into the wound. They are
used initially in the treatment process. Disinfectants are commonly and routinely
used in the management of wounds and they include Savlon, chlorhexidine and
hibitane among others.

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Types of Wound Dressings
Wound dressing is done according to the immediate assessment, the state of the
wound, and objective of the surgeon concerned. The types of wound dressings are:
a. Wet dressings
b. Moisture retentive dressings
c. Occlusive dressings
d. Pressure dressings
e. Medicated dressings

During your clinical experience you have to learn how to dress wounds using the
specific methods as described in your procedure manual. Next, we will look at
burns.
3.7.11 Burns and Scalds

Burns are injuries caused by heat, friction or chemicals.

Scalds are burns caused by hot liquids.

Causes of Burns

Activity 3.8
Write down in your notebook, at least 3 causes of burns.

Well done! Compare your answers with the causes listed below.

The following are causes of burns:

 Open fire that produces flames that can easily burn a person.
 Naked electric wires that can electrocute a person.
 When hot liquids spill on a person they cause scalding.
 Chemicals: when the chemical spills on the skin, a person may end up being
burnt.
 Flammable liquids.
 X-rays or other ionising radiation can destroy the skin and cause injury.

Classification of Burns

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Burns are usually classified according to the depth or degree of skin damaged.
a. First degree burns: these are usually superficial. They are very painful
because of the nerve endings that are not destroyed. The burnt area is
reddish and often heals very fast.
b. Second degree burns (Partial thickness): there is damage to the epidermis
and the superficial dermis. Some parts of dermis are spared. There is
considerable subcutaneous oedema and blister formation. The skin is painful
and red, and if a blister bursts, the area underneath is pink to cherry red in
colour.
c. Third degree (Full thickness): all the layers of the skin are destroyed and the
injury may extend to the underlying fat, muscle and bone. The area is painless
because nerve endings have been destroyed.
You will learn about burns in more detail in the course on Surgery.

First Aid Management of Burns

The following are the aims of first aid management of burns and scalds:
a. Prevent further damage
b. Prevent infection
c. Minimise the effects of loss of fluid from the burnt tissues
d. Reassure the burnt person
e. Transport the casualty swiftly to hospital

Let’s look at each of them in further detail, starting with preventing further damage.

a) Prevent further damage

Separate the casualty from the cause of the burn taking precautions to protect
yourself. Think twice before attempting to rescue someone. If you attempt to rescue
the casualty from a burning house or another building:
 Remember that smoke inhalation is responsible for more deaths from fires
than the actual heat and that a wet or dry cloth across the face will not protect
you from smoke.
 Wear gloves if possible.
 Always open doors carefully. When a door is opened, a blast of hot air and
flames may rush out.

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  Crawl if possible because there will be more air at ground or floor level.
 Remember to search cupboards, wardrobes and under the beds because
people may hide in these places to escape the heat.
 Do not delay! Get the casualty out as quickly as possible.
 Do not panic, if you feel you have lost your way, find your way around the
walls to the door.

b) Prevent infection
The skin is the normal protective covering of the body. When there is damage to the
skin, pathogenic microorganisms may freely enter and multiply rapidly in the tissue
fluids.
 Cover the burnt area quickly with a sterile dressing large enough to cover
more than the burned area.
 Do not burst or break blisters.
 Do not apply any lotion, grease or antiseptic.
 Do not breathe or cough over the burnt area.
 Do not touch the burnt area. Hands are always covered with microorganisms.
 Do not apply cotton wool, fluffy or harmful materials to the burnt area.

c) Minimise the effects of fluid loss from the burnt area

When the skin is damaged, the body is not able to retain body fluids which are part
of every tissue. Conscious burnt adults should be given drinks of water, weak tea or
milk in small amounts every 10 minutes until they reach hospital.

d) Reassure the patient

Remain calm and provide reassurance. An injured person is often frightened.
Then transport the client to the health facility.

Next, we will look at bites and stings

3.7.12 Bites and Stings

Bite wound caused by humans, animals and insects can cause an infection. Dogs
are more likely to bite than cats, but cat bites are more likely to cause an infection.

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Insect bites can be dangerous if they happened to the people with severe allergy to
the insect's venom.

Signs and Symptoms of Allergic Reaction to Bites and Stings

Signs and symptoms of allergic reaction include:

 Swelling around the area where the insect stung the person because of
poison from the insect.
 Redness or discoloration at the site of the bite as a result of the swelling
process.
 Pain due to the swelling process.
 Itching because of body’s reaction to the poison from the insect.
 Decreased consciousness.
 Difficult or noisy breathing.

First Aid Management

The pressure immobilisation technique described below is recommended for bites
and stings from snakes, spiders, and sea animals. You can also use it for bees,
wasps, and ant stings, but only for people with a known allergy to them.

The following is the management of a person with bites or stings:

a. Calm and reassure the casualty
b. Place a small pad and pressure bandage over the bite site. Never wash away
evidence of the venom as this may be used to determine what anti-venom is
required at hospital.
c. Use a crepe bandage to bandage from the extremity, such as finger or toes,
all the way up the limb. Make sure that the tips of the fingers or toes are left
exposed so that you can be checking for circulation.
d. Mark the bite site on the bandage so it can be cut out at hospital without
removing the whole bandage.
e. Tell the patient to stay still until the ambulance arrives.

This treatment is not recommended for the first aid management of other spiders
(including red back), jellyfish, fish stings such as stonefish and bites or stings by
scorpions, centipedes or beetles.

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Next, we will look at fits and convulsions.

3.7.13 Fits and Infantile Convulsions

What are fits or convulsions?

A fit or convulsion occurs when there is a sudden burst of electrical activity in the
brain temporarily interfering with the normal messaging processes. The brain affects
the whole of the body and so where the seizure occurs in the brain, will affect
different parts of the body
First Aid Management
First aid for seizures involves responding in ways that can keep the person safe until
the seizure stops by itself. Here are a few things you can do to help someone who is
having a generalised tonic-clonic (grand mal) seizure:
a. Keep calm and reassure other people who may be nearby.
b. Prevent injury by clearing the area around the person of anything hard or
sharp.
c. Ease the person onto the floor and put something soft and flat, like a folded
jacket, under their head.
d. Remove eyeglasses and loosen ties or anything around the neck that may
make breathing difficult.
e. Do not hold the person down or try to stop their movements.
f. Contrary to popular belief, it is not true that a person having a seizure can
swallow their tongue. Do not put anything in the person’s mouth. Efforts to
hold the tongue down can injure the teeth or jaw.
g. Turn the person gently onto one side. This will help keep the airway clear.
h. Don't attempt artificial respiration except in the unlikely event that a person
does not start breathing again after the seizure has stopped.
i. Stay with the person until the seizure ends naturally and they are fully awake.
j. Do not offer the person water or food until fully alert.
k. Be friendly and reassuring as consciousness returns.
l. Consider a seizure an emergency if any of the following occurs:

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  The seizure lasts longer than five minutes without signs of slowing down or
if a person has trouble breathing afterwards, appears to be in pain or
recovery is unusual in some way.
 The person has another seizure soon after the first one.
 The person cannot be awakened after the seizure activity has stopped.
 The person became injured during the seizure.
 The person becomes aggressive.
 The seizure occurs in water.
 The person has a health condition like diabetes or heart disease or is
pregnant.

Next, we will look at fainting and heat exhaustion

3.7.14 Fainting and Heat Exhaustion

a) Heat Exhaustion
Heat exhaustion is the body's response to an excessive loss of the water and salt,
usually through excessive sweating. Workers most prone to heat exhaustion are
those that are elderly, have high blood pressure, and those working in a hot
environment.
Heat exhaustion is one of the heat-related syndromes, which range in severity from
mild heat cramps to heat exhaustion to the potentially life-threatening heatstroke.

Signs and Symptoms

Signs and symptoms of heat exhaustion often begin suddenly, sometimes after
excessive exercise, heavy perspiration, and inadequate fluid or salt intake. Signs
and symptoms resemble those of shock and may include the following.

 Heavy sweating because of exposure to heat.

 Extreme weakness or fatigue.
 Dizziness and confusion.
 Clammy, moist skin. Sweating leads to water loss and as a result a person
may present with signs of shock.
 Pale or flushed complexion due to loss of fluids through sweating.

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  Muscle cramps. Sweating depletes the body's salt and moisture levels. Low
salt levels in muscles causes painful cramps.
 Slightly elevated body temperature because the person is exposed to
excessive heat.
 Fast and shallow breathing.

First Aid Management

Treat a person suffering from heat exhaustion as follows:
 Have them rest in a cool, shaded or air-conditioned area.
 Have them drink plenty of water or other cool, non-alcoholic beverages.
 Have them take a cool shower, bath, or sponge bath.

The above measures help to cool down the body.

b) Heat Syncope (Fainting

Heat syncope is a fainting (syncope) episode or dizziness that usually occurs with
prolonged standing or suddenly rising from a sitting or lying position. Factors that
may contribute to heat syncope are dehydration and lack of acclimatisation.

Symptoms of Heat Syncope

Symptoms include:
 Light-headedness
 Dizziness
 Fainting

First Aid Management

Take the following steps when a person has fainted:
a. Let the person sit or lie down in a cool place when they begin to feel
symptoms.
b. Let the person slowly drink water, clear juice, or a sports beverage.

Next, we will look at fire and ward accidents.

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3.7.15 Hospital Fire Drill Procedure

Hospitals don’t require full evacuation due to the size and nature of the facility, as
well as the safety of the patients and staff, but there are many other protocols that
determine where patients, visitors, staff, and other occupants in hospitals are
supposed to go — or not go — during a fire emergency.
Practiced adherence to the fire response plan in the form of fire drills ensures staff
are confident in the event of a fire and can remove patients from harm’s way and
manage the situation effectively.
During a fire drill, hospital staff must enact the fire response plan as if a real fire
threat is present.
What’s in a Hospital Fire Response Plan?
A hospital fire response plan will include a general plan to move patients and staff to
safety as well as specific information that is directly related to the facility structure,
staff roles, and more.
Every hospital should have a written fire response plan that includes when and how
to sound and report fire alarms, how to contain smoke and fire, how to use a fire
extinguisher, and how to evacuate areas of refuge. Staff should be trained in each of
these areas, and have their knowledge tested with regular but varied fire drills.
When is the Hospital Fire Response Plan Used?
The hospital fire response plan should be enacted in situations of:
 Fire alarm activation, unless announced test
 Fire or suspected fire
 Fire drills
 Fire preparedness training
General Fire Response Plan for Hospital Fire Drills
A general fire response plan follows the RACE acronym with the additional steps of
Relocation and Evacuation to protect patients in a hospital setting. Let’s go through it
step-by-step.
R
Rescue persons from the room or area. Notify the nurses’ station to get
assistance. Move all people away from where fire, smoke, or the strong smell of
smoke exists. Assist ambulatory patients out of the room and use a wheelchair,

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ordinary chair, blanket drag, or lift and carry with other staff members to move non-
ambulatory patients.
A
Activate the alarm. The alarm may release an audible signal, announce code red,
or chime to alert staff without frightening patients and visitors. Do not shout fire, as
this can cause panic. Pull the nearest alarm to mark to help the fire department to
where the fire danger is present.
C
Close doors to minimize the spread of fire and smoke. All doors should be
closed as quickly as possible, even if no smoke is visible. Patients not in harm’s way
should be returned to their rooms with closed doors.
E
Extinguish the fire if it is safe to do so. Use a fire extinguisher and follow the
PASS procedure (press, aim, squeeze, and sweep). If the situation feels unsafe,
close the door and wait for the fire department to arrive.
Relocation and Evacuation
In cases where the fire spans multiple rooms, patients must be removed from those
adjacent to the fire area to areas beyond fire and smoke barriers.
Elevators should not be used where the fire is located. If an elevator is required to
move a patient to another floor for care, it is acceptable to use an elevator in an
adjacent building that is separated from the fire.
All staff and patients should remain where they are during an alarm or drill, except
for the designated response team. This limits the opening of doors to minimize
smoke and fire spread. All staff will remain in their zone and only open doors to
relocate patients when instructed.
Do not turn off oxygen except when instructed by the fire department, and then only
after all oxygen-dependent patients have been provided with portable oxygen or
relocated where they can receive care.
Priorities for relocation and evacuation:
1. Ambulatory patients
2. Non-ambulatory patients
3. Critical patients
4. Patient records to travel with the patient when possible
Who’s Involved in Hospital Fire Drills?
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Hospital fire drills are meant to involve staff only, without startling patients. Since the
drills are unannounced, staff have the opportunity to practice calm organization and
patient reassurance in addition to their fire emergency response.
Still, there are some exceptions with conducting fire drills to minimize disruption of
patient care and healing. For example, if the drill takes place between 9 pm and 6
am, the audible alarm can be kept silent. Also, in critical care areas, no audible
alarms may be used to prevent risk to sensitive patients.
Individual roles during a fire or fire drill:
 Physicians, including residents and interns, if attending a patient, will remain
in the room with the patient until the conclusion of the fire drill or emergency.
Physicians in patient care areas that are not attending a patient should report
to a nursing station to be available in case of a medical emergency.
Physicians in other non-patient areas should remain in that location until the
all-clear is issued.
 Hospital volunteers may assist staff with closing doors, and reassure
patients of the fire response plan.
 Students will act as visitors and follow instructions to go into closed rooms
during drills or emergencies unless specifically trained to act otherwise.

Checkpoint Question 4
1. Explain the management of a person with a spinal injury
2. List five (5) signs and symptoms of chest injury
3. Outline the first aid management of drowning
4. List four (4) types of wounds
5. Mention three (3) classification of burns

Answers:
1. Management of a person with a spinal injury
a) The victim should not be moved unless absolutely necessary.
b) Without moving the victim, check if the victim is breathing.
c) If they are not breathing, CPR must be initiated;
d) The victim must be rolled while attempting to minimize movement of the spine.
e) If the victim is breathing, immobilise their spine in the position found. The easiest
way to immobilise the spine in the position found is sandbagging. Simply pack

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 towels, clothing or bags of sand among others, around the victim's head such that
it is immobilised.
f) Be sure to leave their face accessible, since you'll need to monitor their breathing.
g) Refer client to health institution immediately.

2. Signs and symptoms of chest injury

a) Presence of dilated neck veins,

b) Dusky or blue lips or nail beds
c) May cough up blood
d) Crackling feeling upon touching victim's skin (sounds and feels like ‘Rice
Krispies’)
e) Difficulties in breathing
f) Shallow breathing
g) Tenderness at site of injury
h) Tracheal deviation,
i) Deformity & bruising of chest

3. First aid management of drowning

a) Act quickly. Remove seaweeds and mud from the nose and throat. Start
artificial ventilation immediately. This is possible even when the casualty is in
water.
b) Turn the victim face down with head to one side and arms stretched beyond
his head. Infants or children could be held upside down for a short period to
drain water.
c) Raise the middle part of the body with your hands round the belly. This is to
cause water to drain out of the lungs.
d) Give artificial respiration until breathing comes back to normal. This may have
to go on for as long as two hours.
e) Remove wet clothing because wet clothes will make person feel cold.
f) Keep the body warm to prevent subnormal temperature, cover with blankets.
g) When victim becomes conscious, give hot drinks such as coffee or tea to make
them feel warm.
h) Do not allow him to sit up.
4. Types of wounds
a) Lacerated

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 b) Incisional
c) Punctured
d) Contused
e) Poisoned
f) Concussion
g) Abrasions
5. Classification of burns
i. 1st Degree burns – these are usually superficial. They are very painful because of
the nerve endings that are not destroyed. The burnt area is reddish and often
heals very fast.
ii. 2nd Degree burns (Partial thickness) - there is damage to the epidermis and the
superficial dermis. Some parts of dermis are spared. There is considerable
subcutaneous oedema and blister formation. The skin is painful and red, if a
blister burst the area beneath is pink to cherry red.
iii. 3rd Degree (Full thickness) - all the layers of the skin are destroyed and the
injury may extend to the underlying fat, muscle and bone. The area is painless
because nerve endings have been destroyed.

Next, we will look at poisoning.

.
3.7.16 Poisoning

What are poisons?

Poisons are substances that cause injury, illness or death. These events are caused
by a chemical activity in the cells. Poisons can be injected, inhaled or
swallowed. Poisoning should be suspected if a person is sick for unknown reason.
Poor ventilation can aggravate Inhalation of poisoning.

Causes of Poisoning
The following may be potential causes poisoning:
 Medications and drug overdose: when medication is taken in excess it
becomes poisonous.

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  Occupational exposure: a person may exposed to chemicals at work and may
end up inhaling them.
 Cleaning detergents/paints: one may ingest cleaning detergents accidentally
or intentionally when they wants to commit suicide.
 Carbon monoxide gas from furnaces and heaters. It is very poisonous.
 Insecticides are poisonous when ingested.
 Certain cosmetics can be poisonous when ingested.
 Certain household plants, have poisonous substances.
 Food poisoning (Botulism). The food we eat can be poisonous especially if not
stored or cooked properly. Even certain types of food like some types of
mushroom have poisonous substances.

Symptoms of Poisoning
 Blue lips indicating insufficient oxygenation because the poison may interfere
with breathing.
 Skin rashes as some people may have an allergic reaction.
 Difficulty in breathing when the poison affects the respiratory system like in
case of carbon monoxide
 Diarrhoea, vomiting, nausea: poisons can irritate the gastrointestinal tract.
 Burns or redness around the mouth and lips, from drinking certain poisons.
 The person’s breath smells like chemicals, such as gasoline or paint thinner.
 Burns, stains and odours on the person, clothing, furniture, floor, rugs or other
objects in the surrounding area.
 Empty medication bottles or scattered pills if a person attempted to commit
suicide.
 Sleepiness, confusion or other unexpected signs.

First Aid Management

Seek immediate medical help.

Take the following steps while waiting for medical help:

a. Try and identify the poison if possible.
b. Check for signs like burns around mouth, breathing difficulty or vomiting.
c. Check and monitor the person's airway, breathing, and pulse. If necessary,
begin rescue breathing and CPR.

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 d. If the person swallowed the poison, remove anything remaining in the mouth
and induce vomiting. If the vomit falls on the skin, wash it thoroughly.
e. If the person vomits, clear the person's airway. Wrap a cloth around your
fingers before cleaning out the mouth and throat. If the person has been
poisoned by a plant part, save the vomit. It may help experts identify what
medicine can be used to help reverse the poisoning.
f. If the suspected poison is a household cleaner or other chemical, read the
label and follow instructions on how to deal with accidental poisoning.
g. In case of convulsions, protect the person from self-injury.
h. If the person has been exposed to poisonous fumes, such as carbon
monoxide, get them into fresh air immediately.
i. If the poison spilled on the person's clothing, skin or eyes, remove the
clothing. Flush the skin or eyes with cool or lukewarm water, for example by
placing them under a shower for 20 minutes or until help arrives.
j. Keep the person comfortable. The person should be rolled onto the left side,
and remain there while getting or waiting for medical help.
k. Take the poison container (or any pill bottles) with you to the hospital.

For inhalation poisoning:

a. Seek immediate emergency help.
b. Get help before you attempt to rescue others.
c. Hold a wet cloth to cover your nose and mouth.
d. Open all the doors and windows.
e. Take deep breaths before you begin the rescue.
f. Avoid lighting a match.
g. Check the victim's breathing.
h. Perform CPR, if necessary.
i. If the victim vomits, take steps to prevent choking.

Steps to Avoid
a. Avoid giving an unconscious victim anything orally.
b. Do not give any medication to the victim unless directed by a doctor.
c. Do not neutralise the poison with lime juice or honey.

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 Some poisons are very strong and may erode the mucous
membrane and cause damage to the tissues they come into contact
with.

Checkpoint Question 6
For each question below, circle the most appropriate answer.
1. The following are causes of poisoning except:
b. Medication
c. Occupation exposure
d. Carbon monoxide
e. Water
2. The signs and symptoms of poisoning include all of the following except:
a. Botulism
b. Blue lips
c. Difficulties in breathing
d. Nausea and vomiting

Answers:
1. D
2. A

3.7.17 Ingesting Corrosives, Strong Acids and Alkaline Substances

A corrosive substance is one that will destroy and damage other substances with
which it comes into contact. It may attack a great variety of materials, including
metals and various organic compounds, but people are mostly concerned with its
effects on living tissue because they cause chemical burns on contact.

Caustics and corrosives cause tissue injury by a chemical reaction. The vast majority
of caustic chemicals are acidic or alkaline substances that damage tissue by
accepting a proton (alkaline substance) or donating a proton (acidic substance) in an
aqueous solution.

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Corrosives are different from poisons in that corrosives are immediately dangerous
whereas poisons may have systemic toxic effects that require time to become
evident. Colloquially, corrosives may be called ‘poisons’ but the concepts are
technically distinct. However, there is nothing which precludes a corrosive from being
a poison; there are substances that are both corrosives and poisons.

Common Types of Corrosive Substances

Common corrosive chemicals are classified into acids and bases. These are:
Acids:
 Toilet bowl cleaning products
 Automotive battery liquid
 Rust removal products
 Metal cleaning products
 Cement cleaning products
 Drain cleaning products
 Soldering flux containing zinc chloride
Alkaline / Bases:
 Drain cleaning products
 Ammonia-containing products
 Oven cleaning products
 Swimming pool cleaning products
 Automatic dishwasher detergent
 Hair relaxers
 Clinitest tablets
 Bleaches
 Cement

Signs and Symptoms

The presence or absence of the following signs and symptoms should be determined
as they may suggest the possibility of significant internal injury.
 Dyspnoea
 Dysphagia
 Oral pain and odynophagia
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  Chest pain
 Abdominal pain
 Nausea and vomiting

However, their absence does not preclude significant injury.

Signs of impending airway obstruction may include the following:

 Stridor
 Hoarseness
 Dysphonia or aphonia
 Respiratory distress, tachypnea, hyperpnoea
 Cough
Other signs of injury may include the following:
 Tachycardia
 Oropharyngeal burns: these are important to identify, however, significant
oesophageal involvement may occur in the absence of oropharyngeal lesions.
 Drooling
 Subcutaneous air
 Acute peritonitis: abdominal guarding, rebound tenderness, and diminished
bowel sounds.
 Haematemesis
 Indications of severe injury - Altered mental status, peritoneal signs, evidence
of viscous perforation, stridor, hypotension, and shock
Investigations
The following are investigation carried out in a person with acid ingestion

Laboratory Studies
 pH testing of products
 A pH less than 2 or greater than 12.5 indicates greater potential for severe
tissue damage.
 A pH outside of this range does not preclude significant injury.
 pH testing of saliva: Unexpected high or low values may confirm ingestion in
questionable cases; however, a neutral pH cannot rule out a caustic ingestion.

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  Complete blood count (CBC), electrolyte levels, BUN levels, creatinine level,
may all be helpful as baseline values and as indications of systemic toxicity.
 Liver function tests may also be helpful to establish baselines or, if abnormal,
confirm severe injury following acid ingestions.
 Urinalysis and urine output may help guide fluid replacement.
 Blood for type and cross are indicated for any potential surgical candidates or
those with the potential for gastrointestinal bleeding.
 Obtain aspirin and acetaminophen levels as well as an ECG in any patient
whose intent may have been suicidal.
 In cases of hydrofluoric acid (HF) ingestion, precipitous falls in calcium level
may lead to sudden cardiac arrest. Although ionized calcium levels are likely
to have too long a turnaround to be clinically useful, cardiac monitoring and
serial ECGs may help anticipate this event.

Imaging Studies
 Chest radiography: Obtain an upright chest radiograph in all cases of caustic
ingestion. Findings may include pneumomediastinum or other findings
suggestive of mediastinitis, pleural effusions, pneumoperitoneum, aspiration
pneumonitis, or a button battery (metallic foreign body). However, the
absence of findings does not preclude perforation or other significant injury.
 Abdominal radiography: Findings may include pneumoperitoneum, ascites, or
an ingested button battery (metallic foreign body).
 If contrast studies are obtained, water-soluble contrast agents are
recommended because they are less irritating to the tissues in cases of
perforation.
 CT will often be able to delineate small amounts of extraluminal air, not seen
on plain radiographs.

First Aid Management

First aid management of a person who has ingested corrosive substances involves
the following steps:
a. Attempt to identify the specific product, concentration of active ingredients,
and estimated volume and amount ingested. Obtain material safety data

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 sheets MSDS) sheets when possible, for workplace exposures. The product
container or labels may be available. Avoid exposure to health care workers.
b. Do not induce emesis or attempt to neutralise the substance by using a weak
acid or base. This induces an exothermic reaction, which can compound the
chemical injury with a thermal injury. It may also induce emesis re-exposing
tissue to the caustic agent.
c. Small amounts of a diluent, although controversial, may be beneficial if
administered as soon as possible after a solid or granular alkaline ingestion,
to remove any adhering particles to the oral or oesophageal mucosa.
d. Water or milk may be administered in small amounts. It is very unlikely to be
of any benefit after more than 30 minutes.
e. Some of the literature available on this topic discourages the use of diluents
because of the concern of inducing emesis resulting in re-exposure of tissue
to caustic agent. Diluents should not be used with any acid ingestion or liquid
alkaline ingestion. The risk of vomiting with re-exposure of the oral or
oesophageal mucosa to the offending substance can result in worsening
injury or perforation.

Checkpoint Question 7
Indicate true(T) or false (F) for the following statements
1. Dysphagia is one of the signs and symptoms of acid ingestion
2. A cough is not a sign of impending airway obstruction

Answers:
1. T
2. F

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3.8 Unit Summary
In this unit, we started by defining key terms used in first
aid. You learnt that first aid is the initial help or treatment
given to a sick or injured person before they can get full
medical attention. We also discussed the aims and
principles of first aid. Next, we discussed bandaging and
splinting. You learnt about the different types of bandages
and splints that can be used to provide first aid at the scene
of an accident or in the case of injury. We then discussed
the methods of lifting and transporting casualties. You learnt
about using a stretcher; the vertical lift; lifting with a strap;
the translation lift; rolling methods and lifting a seated
person.
You then learnt about the first aid management of the
following emergency situations:
 Asphyxia
 Cardiac arrest
 Haemorrhage
 Shock
 Unconsciousness
 Head injuries
 Fractures, sprains and dislocations
 Spinal and chest injuries
 Drowning
 Wounds
 Burns and scalds
 Bites and stings
 Fits and infantile convulsions
 Fainting and heat exhaustion
 Poisoning
 Ingesting corrosives, strong acids and alkaline
substances
You also learnt about how to manage fires and ward

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 accidents.

In the next unit, we will discuss death and grief.

3.9Self-Assessment Questions

1. The following may be potential causes poisoning:

a. Medications and drug overdose
b. Occupational exposure
c. Carbon monoxide gas from furnaces and heaters
d. ALL of the above

2. Signs of impending airway obstruction may include the

following except:
a. Stridor
b. Hoarseness
c. Pain
d. Dysphonia or aphonia

3. Common corrosive chemicals are classified into acids and

bases. The Acids include:
a. Drain cleaning products
b. Ammonia-containing products
c. Rust removal products
d. Oven cleaning products
4. _______________ are substances that cause injury, illness or
death
5. The following are the aims of first aid management of burns
and scalds:
a. Prevent further damage
b. Prevent infection
c. Seek help

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 d. Minimise the effects of loss of fluid from the burnt tissues
6. The following is the cause of burns:
a. Open fire that produces flames that can easily burn a
person.
b. Naked electric wires that can electrocute a person.
c. a and b
d. None of the above

answers
1. d
2. c
3. c
4. Poisons
5. C
6. c

3.10 References and Further Readings

1. Buckwalter, J. A. (1960). A Manual of Bandaging, Strapping
and Splinting. Fourth Edition. AMA Archives of Internal
Medicine, 105(1), 178-179.
doi:10.1001/archinte.1960.00270130194036
2. Dresing, K., & Trafton, P.G. (2014). Casts, splints and support
bandages: nonoperative treatment and perioperative
protection. Place of publication: Thieme.
3. Howard, P.K., Steinmann, R.A., Sheehy, S.S., & Emergency
Nurses Association. (2010). Sheehy's emergency nursing
principles and practice (6th ed.). St. Louis, MO: Mosby Elsevier.
4. Ministry of Health Zambia. (1995). Health Management
Information Systems. Lusaka, Zambia.
5. Newberry, L., Criddle, L.M., Sheehy, S.S., & Emergency
Nurses Association. (2005). Sheehy's manual of emergency
care (6th ed.). St. Louis, MO: Mosby Elsevier.

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 6. Ngugi, E.N. (1984). Practical notes on nursing procedures
(African ed.). London, England: Churchill Livingstone.
7. Potter, P.A. & Perry, A.G. (2009). Fundamentals of nursing (7th
ed.). Canada: Mosby Elsevier.
8. Smeltzer, S.C. & Bare, B.G. (1992). Brunner and Suddarth’s
textbook of medical surgical nursing (7th ed.). New York, NY:
Lippincott Williams & Wilkins.
9. Author Surname and Initials OR Group Author. (2012). Title of
dictionary entry. In Steadman’s medical dictionary for the
dental professions (2nd edition). Lippincott, Williams and
Wilkins.
10. Author or Editors Names. (2007). Title of entry. Microsoft
Encarta dictionary [DVD]. Place of publication: DVD distributor.

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UNIT 4: DEATH AND GRIEF
4.1 Unit Introduction
Welcome to the fourth and final unit in this course. In the last unit, you learnt about
the first aid management of emergencies. In this unit you will learn about death and
grief, which is a normal emotional response to loss. The loss of a loved one is a
difficult and painful human experience, which is often regarded as a serious threat to
health and well-being. In this unit, we will start by defining grief and then discuss the
theories of grief and what influences a person’s experience of grief. We will also
define death and describe the process of dying. You will also learn about the role of
the nurse in caring for terminally ill and dying patients and caring for the patient’s
body after death. Finally, we will discuss the care of the grieving family and the
grieving nurse. As usual, let’s start by reviewing the unit’s learning outcomes.

4.2 Unit Learning Outcomes

Upon completion of this unit, you will be able to:

1. Explain the meaning of grief
2. Describe the theories of grief and
3. Explain the factors that influence grief
4. Outline the role of the nurse in caring for terminally ill and
dying patients
5. Describe the care of the body after death and how to care
for the grieving family and yourself as the nurse.

4.3 What is Grief?

Before you read the following section, take a minute to think about the meaning grief
and then complete the following activity.

Activity 4.1
In your own words, write down a definition of the word grief in
your notebook.

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Good attempt. Compare your answer with the definition given below.

Grief is the emotional suffering that you feel when something or someone you love is
taken away. Often, the pain of loss can feel overwhelming. One may experience all
kinds of difficult and unexpected emotions, from shock or anger to disbelief, guilt,
and profound sadness. The pain of grief can also disrupt ones physical health,
making it difficult to sleep, eat, or even think straight. These are normal reactions to
loss, and the more significant the loss, the more intense ones grief will be
(Helpguideorg International, n.d.).

Let us now look at the theories of grief.

4.4. Theories of Grief

Grief is a normal subjective emotional response to loss. Grief is usually manifested in
thoughts, feelings and behaviours which are unique to an individual and are based
on personal experiences, cultural expectations and spiritual beliefs. Grieving is good
for mental and physical health, as it allows the grieving person to gradually cope with
the loss and to accept it as a reality. The experience of death and grief affects not
only patients and their families but also the nurses who care for them. Grieving can
have positive and negative outcomes on the health of an individual who is grieving.

Some of the symptoms that can accompany grieving are:

 anxiety
 depression
 difficulties in swallowing
 vomiting
 weight loss
 fatigue
 dizziness
 headache
 skin rashes
 chest pain
 heart palpitations
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  excessive sweating
 altered libido
 difficulty concentrating
 disrupted sleeping patterns.

Although grieving can threaten the health of a person, a positive resolution of the
grieving process can enrich the individual with new insights, values, challenges,
openness and sensitivity.

Psychiatrists and psychologists have developed several theorists on the stages of

the grieving process and a series of tasks for survivors to work through their
bereavement and adapt to life with a loss.

In this unit, we will discuss the following theories of grief:

 Kubler-Ross’s stages of grieving

 Engel’s theory of grief
 Bowlby’s phases of mourning

Let’s start by looking at Kubler-Ross’s stages of grieving.

a. Kubler-Ross’s Stages of Grieving

A psychiatrist by the name of Elisabeth Kubler-Ross developed a theory about how
humans process grief, commonly known as the five stages of grief. The framework
for Kubler- Ross’s theory is behaviour oriented and has five distinct stages as
discussed in Table 1 below.

Table 1: Kubler Ross's five stages of grieving (Source: Kubler-Ross, 1969)

Stage Behaviour Responses Nursing Implication
Denial Refuses to accept that loss is Verbally support client’s denial
happening and is not ready to because it serves as a protective
deal with practical problems, function.
such as wearing a prosthesis Examine your own behaviour to
after amputation of a limb. ensure that you do not share in
May assume artificial happiness client’s denial.

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 to prolong denial.
Anger The client or their family may Help the client understand that
direct anger at the nurse or anger is a normal response to
hospital staff about matters that feelings of loss and
normally would not bother them. powerlessness.
Avoid withdrawal or retaliation
with anger and do not take anger
personally.
Deal with the needs underlying
any anger reaction.
Provide structure and continuity
to promote feelings of security
and allow the client to have as
much control over their lives as
possible.
Bargaining Client seeks to bargain to avoid Listen attentively and allow the
loss. client to relieve their guilt and
They may express feelings of irrational fears. Offer spiritual
guilt or fear of punishment for support if appropriate.
past sins, real or imagined
Depression Client grieves over what has Allow the client to express
happened and what cannot be. sadness. They may want to talk
freely about their thoughts and
feelings (for example reviewing
past losses)
Acceptance Client comes to term with loss, Help family and friends
may have decreased interest in understand importance of being
surroundings and support with the client in silence.
persons. They may wish to start Help the client’s family and
making plans. For example friends understand their
writing a will, or preparing decreased need to socialise and
alternate living arrangements. desire for brief guest visits.
Encourage the client to

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 participate as much as possible
in the treatment program.

Next, we will look at Engel’s theory of grief.

b. Engel’s Theory of Grief

George Engel, an American psychiatrist developed a theory of grief where he

identified six stages that a person experiences in the grieving process.

These stages are:

1. Shock and disbelief: the client refuses to accept loss. They accepts it
intellectually but deny it emotionally.

2. Developing awareness: the reality of loss begins to penetrate the

consciousness. Anger may be directed at the hospital, nurse and others. The
client may express emotions such as crying and may also experience self-
blame.

3. Restitution: rituals of mourning, for example funerals.

4. Resolving the loss: attempts are made to deal with the painful void. The
client is unable to accept new love prospects to replace the person they have
lost. They may accept more dependent relationships with their support
system. They think over and talk about memories of the dead person.

5. Idealisation: the grieving person produces an image of the dead person that
is almost devoid of undesirable features. They repress all the negative and
hostile feelings of the deceased. They may experience feelings of guilty and
remorse about past inconsiderate acts to the deceased. Unconsciously they
internalise admired qualities of the dead.

6. Outcome: the person’s behaviour in this stage will be influenced by factors

such as the importance of the lost object or person as source of support,

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 degree of dependence on the relationship, number and nature of other
relationships and number and nature of previous grief experiences.

Next, we will look at Bowlby’s phases of mourning.

c. Bowlby’s Phase of Mourning

John Bowlby was a British psychologist well known for his contribution to attachment
theory. Together with a colleague of his, Colin Parkes, they identified four phases of
mourning that a person experiences when processing grief. Just like the other
theories of grieving an individual can move back and forth between any two of the
phases while processing the loss. The phases of Bowlby’s theory of mourning are as
follows:

 Numbing: this phase may last from a few hours to a week or more. It may be
interrupted by periods of intense emotion. It is the briefest phase of mourning.
The grieving person may describe this phase as feeling unreal. Numbing may
serve to protect the body from the consequences of the loss.

 Yearning and Searching: in this stage there are emotional outbursts of

tearful sobbing and acute distress. It is a painful phase but must be endured.
Anything that tries to avoid or suppress the pain of grief may be just be
prolonging the mourning period. Some of the symptom that can be
experienced during this phase are insomnia, tightness of chest and throat,
loss of appetite, weakness and lethargy.

 Disorganisation and Despair: in this stage the individual may endlessly

examine why and how the loss happened. The person may express anger at
anyone who they think is responsible for the loss.

 Reorganisation – this happens after a year or more. The individual begins to

accept the roles they were not accustomed to and acquire skills and build new
relationships.

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We hope this section has increased your knowledge of the theories of grief. Before
you continue on, answer the questions below as a way of reflecting on what you
have learnt.

CHECKPOINT QUESTION 1

1. Define grief
2. Name any one of the theories of grieving and list the stages of grieving

Answers:
Q1. Grief is an emotional response to loss
Q2.
i. Bowlby’s four phases of mourning

a. Numbing
b. Yearning and Searching
c. Disorganisation and Despair
d. Reorganisation

ii. Engel’s Theory of Grief

a. Shock and disbelief

b. Developing awareness
c. Restitution
d. Resolving the loss
e. Idealisation
f. Outcome

iii. Kubler-Ross’s stages of grieving

a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance

4.5. Factors Influencing Grief

The way an individual perceives a loss and responds to it during bereavement is
heavily influenced by many factors. Before you read the following section, work
through Activity 4.2 which opens our discussion on factors that influence grief.

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 Activity 4.2
Write down in your notebook, at least two factors that influence how
a person experiences grief.

Good attempt! Compare your answers with the factors discussed below.

a. Human Development
The age and developmental stage of a person has a bearing on how one responds
to loss and grief. For example, toddlers are unable to understand loss or death but
they feel anxious over separation from their parents. School-aged children
experience grief over the loss of a body part or function and they associate misdeeds
with causing death. Middle-aged adults usually begin to re-examine life and are
sensitive to their physical changes. Older adults usually experience anticipatory grief
because of aging and the possible loss of self-care abilities. According to Meiner
(2015), older people are often resilient in responding to grief despite it being a highly
stressful process.

b. Significance of the Loss

The significance of a loss depends on the perceptions of the person experiencing the
loss. A number of factors affect the significance of the loss, some of which are:

 Value placed on the lost person, body part and so on.

 Degree of change required because of the loss.
 The person’s beliefs and values.

c. Culture and Ethnicity

How grief is expressed is often determined by the customs of a person’s culture.
Some cultures emphasise self-reliance and independence hence only the nuclear
family and the significant others are involved in handling grief. Other cultural groups
value social support and encourage the expression of loss and other emotions.

d. Socioeconomic Status
The socioeconomic status of an individual affects the support system available at the
time of a loss. Generally, an individual feels greater burden from a loss when there is
a lack of financial or occupational resources.

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 e. Spiritual Beliefs
Spiritual beliefs and practices greatly influence a person’s reaction to loss and
subsequent behaviour. Loss can cause internal conflicts about spiritual values and
the meaning of life. Individuals who have a strong connections to a higher power are
often very resilient and able to face death with relatively minimal discomfort.

f. Sex Role
Men are generally expected to be strong and show very little emotions during grief,
but it is acceptable for women to show grief by crying.

Before you continue, answer the questions below as a way of reflecting on what you
have learnt.

CHECKPOINT QUESTION 2

Indicate Truth(T) or False(F)

The following factors influence grief
1. Degree of change required following the loss
2. Anxiety
3. Gender rolls
4. Weight loss
5. Financial resources
6. Belief in a higher power

Answers:
1. T
2. F
3. T
4. F
5. T
6. T

You now know the meaning of grief, the theories that explore how people grieve and
the factors that influence it. Next, we shall look at how to care for the terminally ill
and dying patients.

4.6. Care for Terminally Ill and Dying Patients

People who face chronic life-threatening illnesses or who are at the end of life
require various interventions including palliative care.

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What is palliative care?
Palliative care is an approach that improves the quality of life of patients (adults and
children) and their families who are facing problems associated with life-threatening
illness. It prevents and relieves suffering through the early identification, correct
assessment and treatment of pain and other problems, whether physical,
psychosocial or spiritual (WHO, 2020).

Palliative care prevents, relieves, reduces, or soothes, the symptoms of a terminal

disease or disorder throughout the entire course of the illness, including care of the
dying and bereavement follow-up for the family.

The World Health Organisation (2011) defines the primary obligations of the
collaborative team offering palliative care as follows:

 Affirming life, and regarding dying as a normal process.

 Neither hastening nor postponing death.
 Providing relief from pain and other distressing symptoms.
 Integrating psychological and spiritual aspect of clients care.
 Offering a support system to help clients live as actively as possible until
death.
 Offering a support system to help families cope during the client’s illness and
their own bereavement.
 Enhance the quality of life.

The nurse provides the following:

 Psychological care
 Expert symptom management
 Promotes client dignity and self-esteem
 Maintains a comfortable and peaceful environment
 Provides spiritual comfort and hope
 Protects against abandonment or isolation
 Offers support to the family
 Assists with ethical decision making
 Facilitates mourning

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Let’s further look at the role of the nurse in providing palliative care:

a) Provide Psychological Care

Towards the end of life, clients experience a range of psychological symptoms,
including anxiety, depression, altered body image, denial, powerlessness,
uncertainty and isolation. Clients and families experience a difficult time when facing
death and dying, including managing their symptoms, creating a support system,
feeling safe, and finding meaning in their circumstances.

You should provide information that helps clients understand their condition, the
course of their disease, the benefits and burdens of treatment options. You should
also help them understand their value and goals of care so that you can preserve the
autonomy of clients who are plagued by not knowing what the future holds or are
uncertain about the goals of care.

b) Manage Symptoms
The primary goal of palliative care is the management of multiple symptoms
commonly experienced by chronically ill or dying clients. Symptom distress,
discomfort, or anguish often complicate a client’s dying experience.

You should continue assessing and reassessing for pain and medication side effects
and applying appropriate interventions to relieve pain and medicinal side effects.

c) Promote Dignity and Self-esteem

A sense of dignity includes a person’s positive self-regard, an ability to invest in and
gain strength from one’s own meaning of life, feeling valued by others, and how one
is treated by caregivers. (Potter & Perry, 2009).

You can promote a client’s self-esteem and dignity by respecting them as a whole
person with feelings, accomplishment and passions, independent of the illness
experience. Spending time with clients as they share their life experiences helps you
know the client better and facilitates the development of individualised intervention.

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Attending to the clients physical appearance promotes dignity and self-esteem.
Cleanliness, absence of bad odours, and attractive clothing gives clients a sense of
worthy. It is important to always provide privacy during nursing care procedures and
to be sensitive when a client and family need time alone.

d) Maintain a Comfortable and Peaceful Environment

A comfortable, clean, pleasant environment helps clients relax, promotes good sleep
patterns, and minimises the severity of symptom. Keep a client comfortable through
frequent repositioning, making sure bed linens are dry, and control extraneous
environmental noise and odours. Pictures, cherished objects and cards or letters
from family members and friends create a familiar and comforting environment for
the dying client in an institutional setting.

e) Promote Spiritual Comfort and Hope

Help the client connect with the spiritual practices of their cultural community. Clients
are comforted when they have assurance that some aspect of their lives will
transcend death. You can even call the client’s spiritual leader to come and talk to
the client because the spiritual concept of hope takes on special significance near
the end of life.

f) Protect against Abandonment and Isolation

Many terminally ill clients fear dying alone. Clients feel more hopeful when others are
near to help them. Family members may find it difficult to accept the situation
regarding the client’s illness and may stop visiting. Whenever they visit, explain to
them the importance of their presence on the client’s comfort and the sense of
belonging it provides.
g) Offers support to the family
Nurses working with people who are dying are in a primary position to provide
support to family members and families as a whole. Family-centered care is an
important part of nursing practice, and, in the context of palliative care, the family as
the unit of care has been central since the inception of the modern hospice and
palliative care movement. The World Health Organization states explicitly that
palliative care should not only improve the quality of life (QOL) for patients but also
for their families. A family’s experience of having an ill member is best understood in
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the context of their relationships with each other, and this becomes even more so
when a family member is ill and is requiring care. Changing patterns of dependency,
reciprocity, and the rewards and challenges that arise influence each family in
different ways. As such, “palliative care is predominantly a family affair,” experienced
uniquely for each family and the individuals in it (Hudson P & Payne S, 2009).
h) Assists with ethical decision making
Physicians and nurses encounter difficulties in their practice of palliative Care. They
do need a good understanding of ethical principles and precedents (Beauchamp TL
& Childress JF, 2001).
Palliative care is mandated in advanced stage incurable cancer and other terminal
chronic illnesses. The different aspects of palliative care such as pain and symptom
control, psychosocial care, and end-of-life issues should be managed in an ethical
manner. The cardinal ethical principles to be followed are-autonomy, beneficence,
non-maleficence and justice. The palliative care experts and team members should
carry out their responsibilities with honesty and dignity. Suffering due to unrelieved
pain and unavailability of morphine are recognized as negligence of human rights.
There are practical ethical challenges which need to be resolved. Truth telling, place
of care, continuity of effective palliative care till the last days of life, confidentiality,
use of antibiotics and blood transfusion, nutrition and advance directives can be the
key points which confront a palliative care team. Progress in palliative care will come
out of good research and medical professionals should undertake trials and studies
in a legal and ethical manner. The delivery of palliative care and medical ethics are
complementary, and use of the two together maximizes the protection and
satisfaction available to the vulnerable patient and family members.

i) Facilitates mourning
Grief is a normal response to loss, any loss: a job, a limb, a life. Clinicians have an
important role in facilitating healthy grieving, and observing for signs of complicated
grief. Grief experienced by dying patients and loved-ones prior to and in anticipation
of death is called anticipatory grief (or mourning); grief of loved-ones following a
death is termed bereavement.
Anticipatory grief for patients involves reviewing one’s life; for families/friends it
means looking to a future without the dying person. Byock has suggested that
patients and families may wish to say to each other, in some way, “Forgive me, I
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forgive you, thank you, I love you and good-bye.” People from different cultural
backgrounds may differ in terms of how and what they want to say or do in
preparation for death. Not knowing or acknowledging that a person is dying will
likely delay or interfere with normal anticipatory grief. Grief reactions in dying
patients may be confused with pain, depression, and even imminent death (e.g.
social withdrawal may imply pain, depression, or anticipatory grief).
The nurse must be honest when discussing prognosis, goals and treatment options;
nothing inhibits normal anticipatory grief more than ambiguity from the physician.
Listen; open the door to meaningful discussion. Ask, “How are you doing with this
recent news?” “Are you scared?” “Tell me what is going through your mind?” Ask for
help – you are not the only health professional available to help with grief. Contact a
physician, social worker, chaplain or psychologist/psychiatrist if you need

assistance. Assess for and aggressively treat pain and depression.

4.7. Death
What is death? Take a minute to think about the meaning of death and then
complete the following activity.

Activity 4.3
In your own words, write down the definition of the word ‘death’ in
your notebook.

Good attempt! Compare your answer with the definitions given below.

Death can be defined as the permanent end of the life of a person (Collins
Dictionary, 2009).
It is the inevitable, permanent, irreversible cessation of all biological functions that
sustain an organism.

A dying person is usually very ill and unlikely to recover. Apart from the signs of
disease the patient is suffering from, a nurse should be able to make an assessment
of the physiological signs of approaching death.

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There are four main characteristic changes that occur in impending death and they
are as follows:

a. Loss of Muscle Tone

This leads to relaxation of the facial muscles making the jaw sag and the patient
experiences difficulties in swallowing and talking. Decreased muscle tone of the
gastrointestinal tract leads to accumulation of gas in intestines leading to a distended
abdomen and retention of faecal matter. The urinary system is also affected leading
to urine incontinence due to decreased sphincter control.

b. Changes in Vital Signs

There is an alteration in the vital signs. The patient’s pulse rate becomes weak and
slow, the blood pressure is decreased. The respiratory rate can be rapid, shallow
and irregular or can be abnormally slow. The patient can also exhibit Cheyne-Stokes
respirations.

c. Slowing of the Circulation

The patient’s skin becomes cold starting with the extremities and there is mottling
and cyanosis of the extremities.

d. Sensory Impairment
The senses of sight, taste and smell start to diminish.

In addition to the four physiological changes, the patient may experience alterations
in the level of consciousness just before death. The patient may progress from being
drowsy and stuporous (numb) to being comatose. The sense of hearing is said to be
the last sense to be lost.

The World Medical Assembly adopted the following guidelines for physicians as
indications of death (Benton,1978):

a. Total lack of responses to external stimuli.

b. Absence of reflexes.
c. No muscular movements, especially breathing.
d. Flat encephalogram.

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In cases of artificial support, absence of electrical currents from the brain for at least
24 hours is an indicator of death. However, life support systems can only be
disconnected after a doctor has certified that the patient is dead.

Cerebral death is another definition of death in which the higher brain centre and the
cerebral cortex is irreversibly destroyed. The patient may still be able to breathe but
is irreversibly unconscious.

Before you continue, answer the questions below as a way of reflecting on what you
have learnt.

CHECKPOINT QUESTION 3

1. ________________________ is the inevitable, permanent, irreversible cessation of all

biological functions that sustain an organism.
2. The following are characteristic that indicate impending death except
a. Loss of Muscle tone
b. Having normal circulation
c. Changes in Vital signs
d. Sensory Impairment

Answers:
Q1. Death

Q2. B

4.7.1 Care of the Body after Death

The care of the body after death is a nurse’s responsibility and it is known as last
offices. You should therefore create an enabling environment in the patient’s room
by removing supplies and equipment and make space to accommodate family
members comfortably, should they wish to view the body and grieve at the bedside.

You should follow the steps outlined below:

a. Remove blood, secretions and intravenous tubing from the body.

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 b. Place absorbent pads under the body to absorb urine or faeces, because the
sphincter muscles relax after death.
c. Place the body in supine position with arms comfortably resting at the bedside
or folded on the chest.
d. Gently loosen the eyelids and place dentures in the mouth to give the person
a more familiar appearance.
e. If the lower jaw is drooping, place a small rolled towel under the chin to close
the mouth.
f. The body needs to be positioned before rigor mortis makes it impossible.
Rigor mortis begins with the jaw and progresses downwards. It usually begins
2-3 hours after death and is complete in 6-8 hours.
g. Give the family members time and privacy if they wish to practice some rituals
or religious practices at the bedside of the deceased.
h. Handle the body respectfully (Refer to the General Nursing Council,
Registered Nurse Procedure manual, 2010).
i. Create a respectful atmosphere in the room through the tone of your voice
and choice of conversation. It is most distressing for family members to hear
laughing or loud discussions coming from the professional care givers who
are providing final care to their deceased loved one.
j. Family members may be invited to help wrap the body.
4.7.2 Care of the Grieving Family

Family members of clients receiving palliative care are affected by the challenges of
caregiving and grief. Nurses need to support, guide, and educate them as they care
for their loved ones. Inform the family members that it is common for clients to have
reduced appetite and feel nauseated by food in the last days of life. Illness,
decreased activity, treatments, and fatigue decrease a client’s caloric needs and
intake.

If possible, explain to the family members the decline in the client’s condition so that
they can offer support to each other. Spiritual care providers may offer comfort and
support for grieving families during and after a death. After a death, assist the family
members with decision making such as notification of the funeral home,
transportation of family members, and collection of the client’s belonging.

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Remember, you are the primary source of support and care. Remember that
because of differing responses to grief, some family members prefer to be alone
while others may want to be surrounded at the time of death.

4.7.3 Care of the Grieving Nurse

When caring for dying clients and families, nurses too experience grief and loss.
Hospice nurses often lose many clients, some of whom they have cared for long
period of time. Before they recover from one loss, they are introduced to another
difficult human story.

Nurses in acute care settings often witness prolonged, concentrated suffering on a

daily basis, leading to feelings of frustration, anger, sadness, or anxiety. Nursing
students report feeling initially hesitant and uncomfortable with their first encounter
with a dying client. They identify feelings of sadness, anxiety and discomfort (Potter
& Perry, 2009).

Talking with friends, a spiritual care provider, or a close professional colleague can
help you recognise your own grief and reflect on the meaning of caring for dying
clients. Creative strategies help you cope with the loss of a person to whom you
have become attached.

You can gain some closure by attending a mortuary viewing or a funeral or writing a
sympathy letter to the family. Stress management technique help to restore your
energy and find joy in caring for clients. In some instances, nurses choose to work
temporarily in settings where grief and death occur less frequently. You need to
develop self-awareness of your feelings and their source as the first step to effective
emotional self-care.

Before we summarise this unit on death and grief, answer the questions below as
way of reflecting on what you have learnt.

CHECKPOINT QUESTION 4

1. Mention the primary obligations of the cooperative team offering

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 palliative care
2. Outline the steps you would take when preparing the body after death

Answers:
Q1.
a. Affirm life, and regard dying as a normal process
b. Neither hasten nor postpone death.
c. Provide relief from pain and other distressing symptoms.
d. Integrate psychological and spiritual aspect of clients care.
e. Offer a support system to help clients live as actively as possible until
death.
f. Offer a support system to help families cope during the client’s illness and
their own bereavement.
g. Enhance the quality of life

Q2.
a. Remove blood, secretions and intravenous tubing from the body.
b. Place absorbent pads under the body to absorb urine or faeces, because
the sphincter muscles relax after death.
c. Place the body in supine position with arms comfortably resting at the
bedside or folded on the chest.
d. Gently loosen the eyelids and place dentures in the mouth to give the face
a more familiar appearance.
e. If the lower jaw is drooping, place a small rolled towel under the chin to
close the mouth.
f. The body needs to be positioned before rigor mortis makes it impossible.
Rigor mortis begins with the jaw and progresses downwards. It usually
begins 2-3 hours after death and is complete in 6- 8 hours.
g. Give the family members time and privacy if they wish to practice some
rituals or religious practices at the bedside of the deceased.
h. Handle the body respectfully.
i. Create a respectful atmosphere in the room through the tone of your voice
and choice of conversation.

4.8 Unit Summary

In this unit you have learnt about grief and death. We
started by defining grief and discussing theories of grief.
You have learnt about Kubler-Ross’s stages of grieving;
Engel’s theory of grief; and Bowlby’s phases of mourning.
You have also learnt that people grieve differently and this
is influenced by: the stage of human development;
significance of the loss; culture and ethnicity;
socioeconomic status; spiritual beliefs; and sex role.
Following this, we have discussed the role of the nurse in

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 caring for terminally ill and dying patients and caring for the
patient’s body after death. We hope you remember the role
you plan when providing palliative care to your clients. In
addition, we have defined death and listed the characteristic
changes that a person displays when dying: loss of muscle
tone; change in vital signs; slowing of the circulation; and
sensory impairment.. Finally, you have learnt about the role
of the nurse in caring for the grieving family and the
importance of caring about your own mental and emotional
health as nurses also experience grief because of the
nature of their work.

You have now come to the end of this course on

Fundamentals of Nursing II. We hope you have found it
interesting and informative. In the next course you will
learn about anatomy and physiology. This is another very
interesting course because it helps you to understand the
structures of the body and how they function.

To find out how you got on in this course, look back at the
learning outcomes at the beginning of this course. If there
are any you are not sure about, please talk to your tutor.
And now before you move on, answer the self-assessment
questions below as a way of reflecting on what you have
learnt in this unit.

4.9 Self-Assessment Questions

1. ___________________ It is the inevitable, permanent,

irreversible cessation of all biological functions that sustain an
organism

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 2. There are four main characteristic changes that occur in
impending death and they are as follows:
a. Loss of Muscle Tone
b. Changes in Vital Signs
c. Sensory Impairment
d. ALL of the above
3. The following are Factors Influencing Grief except;
a. Sensory Impairment
b. Human Development
c. Significance of the Loss
d. Culture and Ethnicity
4. George Engel, an American psychiatrist developed a theory of
grief where he identified six stages that a person experiences in
the grieving process, these include:
a. Disorganisation and Despair
b. Shock and disbelief
c. Yearning and Searching
d. Reorganisation
5. The phases of Bowlby’s theory of mourning include:
a. Resolving the loss
b. Idealisation
c. Numbing
d. Developing awareness
Answers
1. Death
2. d
3. a
4. b
5. c

4.10 References and Further Reading

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 1. Beauchamp TL, Childress JF. Principles of biomedical ethics.
5th ed. Oxford University Press; 2001. [Google Scholar]
2. Benton, R.G. (1978). Death and dying: principles and practice
in patient care. New York, NY: Van Nostrand Company.
3. Byock I. The Four Things that Matter Most. New York, NY:
Simon & Schuster; 2004
4. Collins, J (2009). Definition of death. Retrieved March 14, 2022
from
https://www.collinsdictionary.com/dictionary/english/death#
5. General Nursing Council of Zambia. (2010). Procedure manual
for Registered Nursing. Lusaka, Zambia.

6. Hudson P, Payne S. The future of family caregiving: research,

social policy and clinical practice. Family Carers in Palliative
Care: A Guide for Health and Social Care Professionals. In
Hudson P, Payne S, eds. New York: Oxford University Press;
2009:277–303.

7. Helpguideorg International (n.d.) Coping with grief and loss.

Retrieved from https://www.helpguide.org/articles/grief/coping-
with-grief-and-loss.htm
8. Kubler-Ross, E. (1969). On death and dying. New York, NY:
Macmillan Company.
9. Meiner, S.E. (2015). Gerontologic nursing (5th ed.) Maryland
Heights, MO: Elsevier
10. Potter, P.A. & Perry, A.G. (2009). Fundamentals of nursing (7th
ed.). Canada: Mosby Elsevier.
11. Vera, M. (2022). Nursing care plans (NCP): ultimate guide and
database. Retrieved April 08, 2022, from
https://nurseslabs.com/nursing-care-plans/
World Health Organization. (2020). Palliative care. Retrieved
June 18, 2022, from https://www.who.int/news-room/fact-
sheets/detail/palliative-care

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