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Nursing Fundamental Final Review

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.

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Nursing Fundamental Final Review

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  1. Nursing Fundamental Final Review By: H. Pownell,SPN

  2. Orem Basic Needs Air Water Food Elimination Activity and Rest Solitude and Social Interaction Safety Normalcy

  3. Nursing interventions for maintaining sufficient intake for all OREM’s basic needs…

  4. Air- Maintain Intake Nursing Interventions Assess for breathing difficulty Elevate HOB Up to chair TC&DB Teach about smoking problems Orthopnea position

  5. Air- Symptoms of hypoxia Early: R- Restlessness A- Anxiety T- Tachycardia/ tachypnea Late: B- Bradycardia E- Extreme restlessness D- Dyspnea

  6. Water Intake • Nursing Interventions • Encourage fluids • Supplemental fluids • Offer favorite foods and liquids • Sit up or change positions • Offer something fun: straws, Sippy cups

  7. Food Nursing Interventions provide food pt likes NG/ Gastric tube care Explain nutritional importance's Offer different positions when eating- high fowlers Pure foods

  8. 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

  9. Vital Signs • Temperature • Pulse • Respiration • Blood Pressure

  10. Temperature Basic 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

  11. Temperature terms Elevated Temperaure pyrexia Febrile Hyperthermia Low temperature Hypothermia Affects body temperature age Exercise Hormonal influences Stress Environment Ingestion of hot or cold liquids smoking

  12. Pulses • Pulse – rhythmic beating caused by the heart • Observations nurse must note • Rate • Rhythm • Volume(amp)

  13. 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

  14. Pulse Sites Temporal Carotid Apical Brachial Radial Femoral Popliteal Dorsalis pedal Posterior tibial

  15. 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

  16. Blood pressure 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

  17. 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

  18. Terminally ill Loss: Physical- body function Psychological- 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

  19. Denial/ isolation/ shock • Anger • Bargaining • Depression- reactive mourning or silence • Acceptance Five Stages of grieving/dying Kubler - Ross

  20. Signs of death Approaching death • 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 Clinical signs

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