nursing fundamental final review
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Nursing Fundamental Final Review. By: H. Pownell,SPN. Orem Basic Needs. Air Water Food Elimination Activity and Rest Solitude and Social Interaction Safety Normalcy. Nursing interventions for maintaining sufficient intake for all OREM’s basic needs…. Air- Maintain Intake. - PowerPoint PPT PresentationTRANSCRIPT
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Nursing Fundamental Final Review
By: H. Pownell,SPN
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Orem Basic Needs
Air WaterFoodEliminationActivity and RestSolitude and Social InteractionSafetyNormalcy
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Nursing interventions for maintaining sufficient intake for all OREM’s basic needs…
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Air- Maintain IntakeNursing InterventionsAssess for breathing difficulty Elevate HOBUp to chairTC&DBTeach about smoking problems Orthopnea position
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Air- Symptoms of hypoxia
Early: R- Restlessness A- Anxiety T- Tachycardia/ tachypneaLate: B- Bradycardia E- Extreme restlessness D- Dyspnea
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Water Intake
Nursing Interventions› Encourage fluids› Supplemental fluids› Offer favorite foods and liquids› Sit up or change positions› Offer something fun: straws, Sippy cups
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Food
Nursing Interventions provide food pt likesNG/ Gastric tube careExplain nutritional importance'sOffer different positions when eating- high fowlersPure foods
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Elimination
For BM› Stool softener › Proper diet- fibrous
foods› Enema › Increase fluid
intake
For Urine› Foley Cath.› Increase fluids› Consult doctor› IV› Urine decrease-
prostate problem, multiple pregnancies
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Vital Signs
Temperature Pulse Respiration Blood Pressure
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TemperatureBasic body function, an elevated or low
temperature can indicate a change in health•Regulated by hypothalamus
•Heat lost through skin surface, external environment , head, breathing
•Heat produced by metabolism, exercise, digestion
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Oral Rectal Axillary Tympaanic
Normal 98.6 99.5 97.6 98.6
Description Mouth- under tongue
rectum armpit ear
Contraindication Disease, kids
Diaharrea, bleeding, low BP
Amputation, exposed to external environment
Ear infection
Safety Not in kids mouth
Colonostomy
Safest pressure
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Temperature terms
Elevated Temperaure• pyrexia•Febrile•HyperthermiaLow temperature•HypothermiaAffects body temperature• age•Exercise•Hormonal influences•Stress•Environment•Ingestion of hot or cold liquids•smoking
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Pulses
Pulse – rhythmic beating caused by the heart
Observations nurse must note› Rate› Rhythm› Volume(amp)
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Normal Pulse: 60-100 beats per minute
Tachycardia- above 100 beats per min.Bradycardia- slower than 60 beats per min.Dysrhythmia- disturbance or abnormality in normal heart
rhythme pattern Pulse deficit- difference between radial and apical rate
- listen to apical pulse & second nurse takes radial pulse at same tome
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PU
LSE S
ITES
TemporalCarotidApicalBrachialRadialFemoralPoplitealDorsalis pedalPosterior tibial
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Respirations
Normal- 12- 20 breathes per min.› Tachypenia- rapid respirations greater than 20› Bradypenea- slow respirations less than 12› Cheyne stokes- abnormal pattern of respirations
characterized by alternating periods of apnea & deep rapid breathing
› Orthopnea- different breathing standing and sitting› Rales- abnormal respiration sounds- crackly- fluid build up
on inspiration› Rhonchi- snoring sound- strong crackly- expiration› Wheezing- whistling sound
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BLO
OD
PR
ES
SU
RE
•Pressure exerted by the circulating volume of blood on the arterial walls, veins and chambers of the heart.•Measured in millimeters of mercury •Normals
• 120/ 80• Systolic range
100-140• Diastolic
60-90
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Nursing Process
Assessing- gather data Analyzing- identify
problem, create a nursing diagnosis
Planning- create nursing care plan to meet goals
Implementing- carry out plan
Evaluating- collect objective data to determine changes that need to be made to meet goal
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Terminally ill
Loss:Physical- body functionPsychological- self esteem, identity Sociolcultural- role , heritage Material/ property- loss of possessions
Grief- subjective response of emotional point to loss
Bereavement- common depressed reaction to death of loved one
Mourning- reaction activated by a person to assist in overcoming a great personal loss – defined patterns to express griet
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FIVE S
TAG
ES
OF
GR
IEV
ING
/DYIN
G
Kubler - Ross Denial/ isolation/ shock Anger Bargaining Depression- reactive
mourning or silence Acceptance
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Sig
ns o
f death
Appro
ach
ing d
eath
Clin
ical sig
ns
Changes in vital signs, reflexes, slow thready weak pulse
Decrease in blood pressure Detached , dilated, fixed appearance in
eyes Cool , clammy skin Death rattle- noisy respiration sounds
No movement or breathing Unresponsive No reflexes Flat EKG No apical pulse