RLE FINALS - Intake and Output, O2 Therapy, Post- Mortem Care

Intake and Output

measurement and recording of all fluid intake and output during a 24-hour period.

Intake and Output

it provides important data about the client's fluid and electrolyte balance, and gauges fluid balance and give valuable information about your patient's condition

mL or cc

unit of measurement used is?

100% Fetus

80% Baby at birth

70% Normal adult

50% Elderly person

Percentage of Water

Fetus -

Baby at birth -

Normal adult -

Elderly person -

8

record the type and amount of all fluids the patient received; atleast how many hours

half

Record ice chips as fluid at approximately _____ their volume.

(1) concentration, (2) method of delivery, and (3) liter flow per minute.

Oxygen Therapy - prescribed by the physician who specifies the: 1 _____ , 2 _____ ,3 _____?

low flow oxygen system

For clients with chronic obstructive pulmonary disease (COPD)__________ is essential.

dry, use a humidifier

Oxygen supplied from a cylinder or wall-outlet system is ?

so then we use what to solve the problem

Nasal Cannula or Nasal Prongs

most common inexpensive device. It is easy to apply and permits some freedom of movement. Delivers low concentration of O2 (24-25%) at 2 6L/min.

Face Mask

covers the client's nose and mouth. Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape

Simple Face Mask

delivers oxygen concentrations from 40-60% at 5-8L/min.

Partial Rebreather Mask

delivers oxygen concentrations of 60-90% at 6-10L/min. The oxygen reservoir bag that is attached allows the client to rebreathe about the first 1/3 of the exhaled air in conjunction with oxygen. Thus, increasing FiO2 by recycling expired O2

totally deflate

Bag must not_____________ during inspiration to avoid CO2 buildup.

Non-Rebreather Mask

delivers the highest oxygen concentration possible (95-100%) at 10-15L/min. One-way valves are located on the mask and between the reservoir and mask to prevent the room air and the client's exhaled air from entering the bag.

to prevent the room air and the client's exhaled air from entering the bag

One-way valves are located on the mask and between the reservoir and mask for what ?

Venturi Mask

delivers oxygen concentrations 24-20% or 50 at 4 10L/min. Has wide-bore tubing and color-coded jet adapters that correspond to precise oxygen concentrations and liter flow.

Face Tent

provides varying oxygen concentrations 30-50%at 4 5L/min. Can replace oxygen masks when masks are poorly tolerated by the patient

Face Tent

Can replace oxygen masks when masks are poorly tolerated by the patient

Transtracheal Oxygen Delivery

may be used for oxygen-dependent clients. Oxygen is delivered via a small, narrow plastic cannula, surgically inserted through the skin and directly into the trachea. A chain around the neck holds the catheter in place. The client requires less oxygen because all of the flow delivered enters the lungs.

2-3

Keep the catheter patent (1.5mL of NSS). Clean the rod in and out of it. Then, inject again 1.5mL of NSS. This must be done how many times a day

Oxygen Hood

a rigid plastic dome that encloses an infant's head. Gas should not be allowed to be blown directly into the infant's face.

Oxygen Tent

- consists of a rectangular, clear, plastic canopy with outlets that connect to an oxygen or compressed air source and to a humidifier that moisturizes the air or oxygen. It delivers approximately 30% concentration of oxygen

15

Flood the tent with ?L/min for about 5min., then adjust to 10-15L/min.

Post-Mortem Care

care provided to a patient immediately after a person's death

Dying Process

often accompanied by a myriad of psychological, spiritual, and physical needs; nurses are in the ideal position to identify and address them.

Denial

not ready to deal with practical problems; may assume artificial cheerfulness.

Anger

client and family have feelings of resentment, envy, or anger directed at client, family, health care, providers, God, and others

Bargaining

seeks to bargain to avoid loss. The client or his/her family asks for more time to reach an important life event and may make promises to God and others.

Depression

grieves over what has happened and what cannot be.

Acceptance

comes to terms with loss. May have decreased interest in surroundings and support persons; may wish to begin making plans.

Cognition or Orientation

May be agitated or restless. • Cannot subjectively respond to verbal stimuli.

Cardiovascular

Tachycardia, irregular heart rate. • Low blood pressure or significant widening between systolic and diastolic pressures. • Dehydration.

Pulmonary

Tachypnea, dyspnea. • Acetone breath. • Cheyne-Stokes breathing. • Pooling of secretions or noisy respirations.

Gastrointestinal

Diminished appetite. • Smaller amount of feces. • Incontinence.

Renal

Diminished urine output. • Incontinence. • Concentrated urine.

Motility

Limited mobility. • Bedfound.

Heart-Lung Death

clinical signs include the cessation of the apical pulse, respirations, and blood pressure.

24

In instances of artificial support, absence of brain waves for at least ___hrs. indicates death,

Cerebral Death or Higher Brain Death

cerebral cortex is irreversibly destroyed. It is a clinical syndrome characterized by: Absence of responsiveness ➢ Absence of cephalic reflexes ➢ Apnea ➢ Isoelectric encephalogram

Cerebral Death or Higher Brain Death

It is a clinical syndrome characterized by: Absence of responsiveness ➢ Absence of cephalic reflexes ➢ Apnea ➢ Isoelectric encephalogram

Infancy-5 Years Old

❖ Does not understand concept of death. ❖ sense of separation forms basis for later understanding of loss and death. ❖ Believes death is irreversible, a temporary departure, or sleep. ❖ Emphasizes immobility and inactivity as attributes of death.

5-9 Years Old

❖ Understands that death is final. ❖ Believes own death can be avoided. ❖ Associates death with aggression or violence. ❖ Believes wishes or unrelated actions can be responsible for death.

9-12 Years Old

❖ Understand death as the inevitable part of life. ❖ Begins to understand own mortality, expressed as interest in the afterlife or as fear of death. ❖ Expresses idea about death gathered from parents or older adults.

12-18 Years Old

❖ Fears a lingering death. May fantasize that death can be defied, acting out defiance through reckless behaviors. ❖ Seldom thinks about death, but views it in religious and philosophic terms. ❖ May seem to reach "adult" perception of death but emotionally unable to accept it.

18-45 Years Old

❖ Has attitude toward death influenced by religious and cultural beliefs.

45-65 Years Old

❖ Accepts own mortality. ❖ Encounters death of parents and some peers. ❖ Experiences peaks of death anxiety. ❖ Death anxiety diminishes with emotional well-being.

65 Years Old and Above

❖ Fears prolonged illness. ❖ Encounters death of family members and peers. ❖ Sees death as having multiple meanings (e.g., freedom from pain, reunion with already deceased family members).

Rigor Mortis

stiffening of the body that occurs about 2-4 hours after death. Starts in the involuntary muscles (e.g., heart, bladder, etc.) then progresses to the head, neck, trunk, then extremities

Algor Mortis

gradual decrease of the body temperature after death, due to termination of blood flow to the hypothalamus, hence its thermoregulation ceases and there is a drop of 1°C/hr.

Algor Mortis

Simultaneously, the skin loses its elasticity and can easily be broken when removing dressings and tapes.

Liver Mortis

discoloration of the tissues because of hemolysis and hemoglobin release. It appears in the lowermost, dependent areas of the body.

Embalming

prevents the degradation process through injection of chemicals that destroy bacteria.

Shroud

piece of plastic or cotton material to enclose a body after death