Nursing Fundamental Final Review

By: H. Pownell,SPN

Orem Basic Needs

Air WaterFoodEliminationActivity and RestSolitude and Social InteractionSafetyNormalcy

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

Air- Maintain IntakeNursing InterventionsAssess for breathing difficulty Elevate HOBUp to chairTC&DBTeach about smoking problems Orthopnea position

Air- Symptoms of hypoxia

Early: R- Restlessness A- Anxiety T- Tachycardia/ tachypneaLate: B- Bradycardia E- Extreme restlessness D- Dyspnea

Water Intake

Nursing Interventions› Encourage fluids› Supplemental fluids› Offer favorite foods and liquids› Sit up or change positions› Offer something fun: straws, Sippy cups

Food

Nursing Interventions provide food pt likesNG/ Gastric tube careExplain nutritional importance'sOffer different positions when eating- high fowlersPure foods

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

Vital Signs

Temperature Pulse Respiration Blood Pressure

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

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

Temperature terms

Elevated Temperaure• pyrexia•Febrile•HyperthermiaLow temperature•HypothermiaAffects body temperature• age•Exercise•Hormonal influences•Stress•Environment•Ingestion of hot or cold liquids•smoking

Pulses

Pulse – rhythmic beating caused by the heart

Observations nurse must note› Rate› Rhythm› Volume(amp)

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

PU

LSE S

ITES

TemporalCarotidApicalBrachialRadialFemoralPoplitealDorsalis pedalPosterior tibial

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

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

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

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

FIVE S

TAG

ES

OF

GR

IEV

ING

/DYIN

G

Kubler - Ross Denial/ isolation/ shock Anger Bargaining Depression- reactive

mourning or silence Acceptance

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