2.  Air  Water  Food  Elimination  Activity and Rest  Solitude and Social Interaction  Safety  Normalcy

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

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

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

8.  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.  Temperature  Pulse  Respiration  Blood Pressure

11. OralRectalAxillaryTympaanic Normal98.699.597.698.6 DescriptionMouth- under tongue rectumarmpitear ContraindicationDisease, kids Diaharrea, bleeding, low BP Amputation, exposed to external environmen t Ear infection SafetyNot in kids mouth ColonostomySafestpressure

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

13.  Pulse – rhythmic beating caused by the heart  Observations nurse must note › Rate › Rhythm › Volume(amp)

14. 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

15.  Temporal  Carotid  Apical  Brachial  Radial  Femoral  Popliteal  Dorsalis pedal  Posterior tibial

16.  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

17. 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

18.  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

19. 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

20. Kubler - Ross  Denial/ isolation/ shock  Anger  Bargaining  Depression- reactive mourning or silence  Acceptance

21. Approaching death Clinical signs  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