Topic 2.

Intravenous Fluid Therapy • hypertonic fluids

Definition • has a greater concentration of
Intravenous therapy is the aseptic solutes
instillation of fluid, electrolyte, nutrients, • pulls fluid and electrolytes from
and medication through a needle into a the intracellular and interstitial
vein. compartments into the
• for clients who can’t take food or intravascular compartment
fluid orally
Intravascular space
• dependent nursing action

IV Fluids interstitial space

• solution given. it is most often clear,
but can be other colors
• may be in a glass bottle or a plastic
bag
• in a various size
• sometimes a dark colored plastic cells
bag may cover the IV fluid to protect
it from the light
Isotonic solution does not alter the cell
Types of Fluids as the solution has the same
• isotonic fluids concentration of solutes as with the
• having the same concentration blood plasma
of solutes as blood plasma
• remain inside the intravascular
compartment, thus expanding it
Intravascular space

interstitial space

cells

• hypotonic fluids Hypotonic solution tends to swell the cell

• lesser concentration of solutes as fluids are being drawn inside the cell
• dilutes the serum, which due to the cell’s higher concentration of
decreases serum osmolarity solutes
Intravascular space

interstitial space

cells
Hypertonic solution tends to shrink the • Hypotonic Solutions
cell and eventually dehydrating it due to • 0.45% NaCl
its higher solute concentration thus • 0.33% NaCl
drawing the fluids inside the cell outside.

• Hypertonic
• 5% Dextrose in normal saline
(D5NSS) (Yellow)
• 5% Dextrose in 0.45% NaCl (D5
½ NSS)
• 5% Dextrose in Lactated
Ringer’s (D5LR) (Pink)

Learning Activity: Formulate a

scenario wherein these solutions can be
used to the patient.

Selected IV Solutions
• Isotonic Solutions
• 0.9% NaCl (PNSS)
• Lactated Ringer’s (PLR)
Classification
• 5% Dextrose in Water (D5W)
1. Nutrient
 Contains some CHO
(carbohydrate which consists of
C-carbon, H-hydrogen, and O-
oxygen) and H20
 Useful in preventing dehydration
 Insufficient calories
Ex.: 5% Dextrose in Water, 0.45%
Sodium Chloride
2. Electrolyte  BASILIC VEIN
 contains varying number of
cations and anions
Ex.: 0.9% Sodium Chloride, Ringer’s
solutions (sodium, chloride,
potassium, calcium), Lactated
Ringer’s solution
3. Volume Expanders
 used to increase the blood
volume following severe blood
loss or loss of plasma
Ex.: Dextran, Plasma, Albumin

Sites of IV Therapy
Considerations
 Client’s age
 Length of time
 Type of solution used
 Condition of veins

 GREAT SAPHENOUS VEIN AND

DORSAL PEXUS

Other sites:
 DORSAL METACARPAL VEIN

 CEPHALIC VEIN
Intravenous Devices Butterfly Needle
 Butterfly Needles –These are small
gauge needles. The needles have
plastic wings on the shaft to facilitate
placement. Plastic tubing of various
lengths extends behind the needle.
Butterfly catheters are usually
placed in the cephalic vein. These
catheters are easy to place but
difficult to maintain. Of the various
catheter types, the butterfly is the Over-the-Needle Catheter
least stable and easily punctures the
vessel wall, allowing for
subcutaneous infiltration of fluids. To
reduce the risk of vessel puncture,
tape directly behind the catheter
wings rather than over the wings
when securing the catheter.
 Note: butterfly needles should only
be used for IV infusions of five
hours or less  Infusion Set – A collection of sterile
devices designed to conduct fluids
from an intravenous (IV) fluid
container to a patient’s venous
system; used for gravitational
intravenous administration.

 Over-the-needle Catheters –the

most common type of catheter
used today. It is inexpensive and
easy to place. It is used primarily for
peripheral vein catheterization. This
type of catheter is fitted outside or
over a steel needle. The needlepoint
extends a millimeter or so beyond
the catheter tip for entry into the
vein. Once the venipuncture has
been made, the catheter is slid off
the needle and into the vein. Over-
the-needle catheters are available in
a variety of lengths and gauges and
are also made of various materials.
 Macrodrip – A spike that allows large Burette Set
volumes of fluid to flow from a bag
into a collecting chamber and then
into a patient, who requires rapid
fluid resuscitation.

 Microdrip –Tubing is narrower and

so produces smaller drops. It is used
for children and infants, or to infuse
sensitive medications where
precision in the flow rate is essential.
Macrodrip Microdrip

Dial Flow Set

Macrodrip Microdrip
Advantages: Advantages:
 Allows fast fluid  Easy to titrate
infusion  Avoid fluid
 Allows fluid overload
resucitation
 Allows fluid
boluses
Disadvantges: Disadvantages:
 Potential for  Does not allow
fluid overload fluid resucitation
 Difficult to titrate  Does not allow Electronic Infusion Device
fluid boluses
 Measured Volume Sets – delivers
specifically measured volumes
Ex.: Burette set, SoluSet, and Dial
flow set

 Electromechanical Infusion
Devices/Electronic Infusion Device
(EID) – A device for monitoring
intravenous infusions. The Device
may have an alarm in case the flow
is restricted because of an occlusion
of the line. In that case, the alarm
will sound when a preset pressure
limit is sensed.
Intravenous Flow Rate Calculation Sample Macrodrip with drop factor
 IV fluids may be infused by gravity
using a manual roller clamp or dial-
a-flow, or infused using an infusion
pump. Regardless of the method, it
is important to know how to calculate
the correct IV flow rate.

Standard Formula
Drip Rate = _Volume (mL) _
Time (hr)

Duration = Volume (mL)

Drip Rate (mL/hr)

Rate (dpm) = Volume (mL) x gtt factor

Duration (hr) x 60min/hr

 Where:
o Drip Rate = volume over time
o Volume = the amount of IV
Solution ordered
o gtt = drops
o gtt factor = drop factor (either
macro set or micro set)
 Macroset = 10, 12, 15, or
20gtt/mL (depending on the
indication of the
manufacturer on the
package)
 Microset = 60gtt/mL
(it is always at 60gtts/mL)
o Duration = hours to administer
the solution
o Rate (dpm) = drip rate in drop
per minute
Note: Drop factor (gtt factor) and
60min/hr are constant variables; cc
and ml are interchangeable units

Example:
1. The physician has ordered 1000ml
Lactated Ringers to infuse over 8
hours. You have a macrodrip tubing
with a drop factor of 15 gtts/mL.
Calculate how many gtts/min to set
as the IV flow rate.

Step 1: Determine which IV tubing

you will be using, microdrip or Remember: You can see this on the
macrodrip, so you can use the package of your infusion set.
proper drop factor in your
calculations.
Step 2: Identify the formula to use and Sample Microdrip with drop factor
your variables.

Rate (dbm) = _Volume (mL) x gtt factor_

Duration (hr) x 60min/hr

Rate (dbm) = 1000mL x 15gtts/mL

8hrs x 60min/hr

Rate (dbm) = 1000 x 15gtts

8 x 60min

= 31.25gtts/min

Step 3: Always remember to round off

your calculated answer since you
cannot count the drops in fraction. So
instead of 31.25gtts/min, it will be
31gtts/min.

Answer: 31gtts/min

2. The physician has ordered 500mL of

D5NSS to run for 12 hours with a
microdrip set. Calculate how many
gtts/min to set as the IV flow rate.

Rate (dbm) = _Volume (mL) x gtt factor_

Duration (hr) x 60min/hr

Rate (dbm) = 500mL x 60gtts/mL

12hrs x 60min/hr

Rate (dbm)= 500mL x 60gtts/mL

12hrs x 60min/hr

Rate (dbm) = 500 x (1)gtts

12hrs x min

= 41.67gtts/min

Rate (dbm) = 42gtts/min

3. Ancef 1gm in 100ml normal saline to

be infused over 30 minutes. You
have macrodrip tubing with a drop
factor of 20gtts/ml. Calculate how
many gtts/min to set as the IV flow
rate.

Rate (dbm)= 100mL x 20gtts/mL

0.5hrs x 60min/hr Remember: You can see this on the
package of your infusion set.
Rate (dbm) = 67gtts/min
4. The doctor orders 1L bag of IV Common Complication of
Normal Saline to infuse at a rate of Intravenous Therapy
50mL/hr. How long will it take for the 1. Infection – occur from the entry of
IV bag to completely infuse? microorganism into the body through
venipuncture.
Duration = Volume (mL)
Drip Rate (mL/hr)

Duration = 1000mL= 20 hours

50mL/hr

Factors that affect flowrate

1. Flow is directly proportional to the
height of the liquid column.
2. Flow is directly proportional to the
diameter of the tubing.
3. Flow rate is inversely proportional to
the length of the tubing.
4. Flow is inversely proportional to the
viscosity of the fluid.

Other factors affecting flowrate

1. Age
2. Condition of patient
3. Solution used  S/sx: Redness, swelling and
4. Manufacturer’s drop factor drainage at the IV site
5. Patency of the needle  Nursing Care:
6. Position of the site o Strict aseptic technique, monitor
signs of systemic infection,
7. Height of the IV pole
discontinue IV
8. Kinking of the tube
2. Infiltration –occurs when I.V. fluid or
medications leak into the
surrounding tissue. Infiltration can be
caused by improper placement or
dislodgment of the catheter. Patient
movement can cause the catheter to
slip out or through the blood vessel
lumen.

 Cause: Cannula dislodgement or

perforation of wall of vein.
  S/sx: Leakage of IV fluid, place, site of cannula inserted,
discomfort, fluid flow becomes microorganism at the time of
slow or ceased, sometimes insertion.
absence of blood backflow  S/sx: Redness, warm area, pain,
 Nursing Care: tenderness
o Stop infusion and remove
cannula immediately, elevate
limb, apply warm or cold
compressors.
o Using appropriate size and type
of cannula and a good fixation
technique prevents this problem.

3. Extravasation – It is similar to
infiltration, with an advertent
administration of vesicant solution or
medication into the surrounding
tissue such as chemotherapeutic
agents, dopamine, calcium
preparations. This can lead to
blisters, inflammation, and tissue
necrosis.

 Nursing Care:
o Discontinue the IV and apply
cold compressors (later on warm
compressor)
o Keep the site elevated
o To avoid phlebitis, use strict
aseptic techniques
o Rotate IV site every 72 hours as
per policy or as needed.
o Daily dress the site or as needed

Vein Selection Guidelines

 Nursing Care  Use distal veins of the arms first
o Similar to infiltration, use of  No dominant hand whenever
antidote according to the policy, possible
throughout neurovascular
 Avoid using veins that are:
assessment of affected extremity
o Areas of flexion
and must be performed
o Highly visible
frequently.
o Damage by previous use
o Continually distended
4. Phlebitis – inflammation of a vein
o Surgically compromised or
related to a chemical or mechanical injured extremity
irritation or both.
 Cause: Risk of phlebitis increases
with the length of time IV line is in
 Side Drip
or
piggyback

or main
line
Intravenous Fluid Sheet of San Pedro Hospital

Note: Always remember to use the right color of pen when transcribing in this sheet.
Information regarding the patient’s name, ward, and room number should be written
using black or blue pen. Make sure to write your full name with signature over printed
name.
Topic 3. Intake and Output (I&O)  Congestive heart failure
Water is essential for life and  In case of dehydration
maintaining the correct balance of fluid  Decreased or little urine output
in the body is crucial to health.  Dry mucous membrane
Measuring intake and output chart is  Any bleeding
one of the most basic methods of  Excessive perspiration
monitoring a client’s health. Accurate 24  Dark concentrated urine
hours measurement and recording is an
essential part of patient assessment. In Importance of measuring fluid I&O
critically ill patient, it becomes very
important to accurately record fluid
intake and output for proper evaluation
and control of fluid balance. Accuracy in
recording fluid intake and output is vital
to the overall management of certain
patient groups and facilitate correct
prescribing of intervention and
subcutaneous fluids.

 It is defined as the measurement

and recording of all fluid intake and
output during a 24-hour period. It
provides important data about the  Physician diagnosis and treatment
client’s fluid and electrolyte balance. may depend on accurate
 Unit of measurement of intake and measurement of I&O.
output is mL (milliliter)  Measurement of I&O can monitor
 To measure fluid intake, nurses progress of treatment or of a
convert household measures such disorder
as glass, cup, or soup bowl to metric  This provides information about
units. retention or loss of sodium and
 Gauge fluid balance and give ability of the kidneys to concentrate
valuable information about your or dilute urine in response to fluid
patient’s condition. change
 It helps determine the patient’s fluid
Purpose of I&O calculation status:
 Ensure accurate record keeping o Are they hydrated?
 Prevent circulatory overload o Are they dehydrated?
o Is there fluid overload?
 Prevent dehydration
o Is there an obstruction?
 Aids in analyzing trends in fluid
status
What to consider for patient’s intake?
 Contributes to accurate assessment
 Oral fluids
record
 Yogurt
Indication of I&O chart  Jelly (JELL-O)
 Fluid and electrolyte imbalance  Ice chips (melts to half its volume)
 Kidney impairment  Foods that tend to become liquid at
room temperature
 In case of dialysis patient
 Tube feedings
 Client’s with burns
 Parenteral fluids
 Recent surgical procedure
 Intravenous medications
 Severe vomiting or diarrhea
 Intravenous and tube feeding
 Taking diuretics or corticosteroids
 Catheter or tube irrigants
What to consider for patient’s o Regard intake and output
output? holistically because age,
 Urine diagnosis, medical, problem, and
 Vomitus and liquid feces type of surgical procedure can
 Tube drainage affect the amounts. Evaluate
 Wound drainage and draining trends over 24 to 48 hours.
fistulas
 DONT'S
Clinical Do’s and Dont's o Don’t delegate the task of
 DO’S recording intake and output until
o Identify whether your patient has you’re sure the person who’s going
undergone surgery or if he has a to do it understands its
medical condition or takes importance.
medication that can affect fluid o Don’t assess output by amount
intake or loss. only. Consider color, color
o Measure and record all intake and changes, and odor too.
output. If you delegate this task, o Don’t use the same graduated
make sure you know the totals and container for more than one
the fluid sources. patient.
o At least every 8 hours, record the
type and amount of all fluids the
patient received and describe the
route as oral, parenteral, rectal, or
by enteric tube.
o Record ice chips as fluid at
approximately half their volume.
o Record the type and amount of all
fluids the patient has lost and the
route. Describe them as urine,
liquid stool, vomitus, tube drainage
and any fluid aspirated from a
body cavity.
o If irrigating a nasogastric or
another tube or the bladder,
measure the amount instilled and
subtract it from total output.
o For an accurate measurement,
keep toilet paper out of your
patient’s urine.
o Measure drainage in a calibrated
container. Observe it at eye level
and take the reading at the bottom
of the meniscus.
o Evaluate patterns and values
outside the normal range, keeping
in mind the typical 24h-hour intake
and output
o When looking at 8-hour urine
output, ask how many times the
patient voided, to identify
problems.
Intake and Output Sheet of San Pedro Hospital

Note: You can place emesis or other discharges on the “others” column. 3/11 nurse on
duty is the one who closes the computation in San Pedro Hospital.

Learning Activity: Compute for the total Intake and Output

You are assigned to a 9-year-old female patient. Upon receiving her at 7am, you
observed that she has a foley catheter attached to a urobag. You asked her when was
the last time her urine bag was emptied. She replied that it was around 3am this
morning. So, you drained it and noted that the urine level was approximately 300cc. You
also observe that she has an IVF line of D5LR iL at 80cc/hr (microset) at 700mL level. At
8:30am, she reported to drink 100cc of orange juice. After 3 hours, she vomited approx.
87mL of coffee ground emesis. At the end of your shift (3pm), her urine bag was noted
to have 90 cc of urine and her IVF is at 50 cc level.
Topic 4. Oxygen Therapy body part, like a finger. Low levels mean
Oxygen, a gas found in the air we that a person may be a good candidate
breathe, is necessary for human life. for supplemental oxygen.
Some people with breathing disorders
can’t get enough oxygen naturally. They Normal levels of arterial blood oxygen
may need supplemental oxygen, or are between 75 and 100 mmHg
oxygen therapy. People who receive (millimeters of mercury). An oxygen
oxygen therapy often see improved level of 60 mmHg or lower indicates the
energy levels and sleep, and better need for supplemental oxygen. Too
quality of life. much oxygen can be dangerous as well,
 It is prescribed by physician and and can damage the cells in your lungs.
specifies the concentration of Your oxygen level should not go above
delivery, and liter flow per minute 110 mmHg.
 Nurses may initiate administration of
O2 in emergency situations. Some people need oxygen therapy all
the time, while others need it only
occasionally or in certain situations.
Some oxygen therapy is done at a
doctor’s office, and other times people
have an oxygen supply in their homes,
or a portable oxygen system.

What are the symptoms of low

oxygen?
When you aren’t getting enough oxygen,
you’ll experience a host of symptoms,
including:
Who needs oxygen therapy?
 rapid breathing
Oxygen therapy is prescribed for people
 shortness of breath
who can’t get enough oxygen on their
 fast heart rate
own. This is often because of lung
 coughing or wheezing
conditions that prevents the lungs from
 sweating
absorbing oxygen, including:
 confusion
 chronic obstructive pulmonary
 changes in the color of your skin
disease (COPD)
 pneumonia
Safety precautions during oxygen
 asthma
therapy
 bronchopulmonary dysplasia,
underdeveloped lungs in newborns  “No smoking” sign must be in place
 heart failure
when oxygen is in use.
 cystic fibrosis  Make sure electrical devices are in
 sleep apnea good working order.
 lung disease  Avoid materials which can generate
 trauma to the respiratory system static electricity.
 Avoid the use of volatile and
To determine whether a person will flammable substances.
benefit from oxygen therapy, doctors  Ground electric monitoring devices.
test the amount of oxygen in their  Make known the location of fire
arterial blood. Another way to check is extinguishers.
using a pulse oximeter that indirectly Note: Oxygen is odorless, tasteless,
measures oxygen levels, or saturation, and colorless
without requiring a blood sample. The
pulse oximeter clips onto a person’s
Oxygen Delivery Systems o Simple mask
 Nasal Cannula  delivers oxygen
concentrations from 40-60%
at 5-8L/min

o Partial rebreather mask

 delivers O2of 60-90% at
o Aka “nasal prongs” 6-10L/min
o Most common inexpensive
device
o Easy to apply
o Permits some freedom of
movement
o Delivers low concentration of
O2(24-45%) at 2-6L/min

 the oxygen reservoir bag that

is attached allows the client
to rebreathe about the 1st
third of the exhaled air in
conjunction with oxygen.
Thus, increasing FiO2 by
recycling expired O2.

o Non-Rebreather Mask
 Delivers the highest
O2concentration possible
(95-100%) at 10-15L/min
 Face Mask

o Covers the client’s nose and

mouth  One-way valves on the mask
o Exhalation ports on the sides of and between the reservoir
the mask allow exhaled carbon bag and mask prevents the
dioxide to escape room air and client’s exhaled
air from entering the bag
o Venturi Mask  A chain around the neck
 Delivers O2 concentrations holds the catheter in place
50% at 4-10L/min  Client requires less
O2because all of the flow
delivered enters the lungs
 Nursing Alert: Keep
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 2-3 times a day.
o Oxygen Hood

 Has wide-bore tubing and

color-coded jet adapters that
correspond to precise O2
concentration and liter flow

o Face Tent  Is a rigid plastic dome that

 Can replace O2 masks when encloses an infant’s head
masks are poorly tolerated  Gs should not be allowed to
by patient blow directly into the infant’s
 Provides varying face
concentration of O2 (30-50% o Oxygen Tent
at 4-5L/min)

o Transtracheal Oxygen Delivery  Consists of a rectangular,

 May be used for O2- clear, plastic canopy with
dependent clients outlets that connect to an
 O2 is delivered via a small, oxygen or compressed air
narrow plastic cannula source & to a humidifier that
surgically inserted through moisturizes the air or oxygen.
the skin directly into the  Delivers approximately 30%
trachea concentration of O2
 Cover the child with a gown
or cotton blanket (protect
against chilling)
 Flood the tent with 15 L/min
for about 5 minutes, then
adjust to 10-15 L/min.
Topic 5. Post Mortem Care - “This can’t be true.”
It is the care provided to a patient - “I’ll be just fine after surgery.”
immediately after death. - Not ready to deal with practical
problems
- May assume artificial
cheerfulness

2. Anger – When the individual

recognizes that denial cannot
continue, they become frustrated,
especially at proximate individuals.

Purpose
 Preparing the patient for viewing by
family
 Ensuring proper identification of the
patient prior to transportation to the
morgue or funeral home
 Providing appropriate disposition of
patient’s belongings
 Maintaining vital organs, if donation
is planned - “Why me?”
Dying Process - Client and family have feelings of
 Is often accompanied by a myriad of resentment, envy, or anger
psychological, spiritual, and physical directed at client, family, health
needs, and nurses are in the ideal care providers, God, and others
position to identify and address
them. 3. Bargaining – the third stage involves
Kubluer-Ross Stages of Dying (Loss the hope that the individual can
and Grief) avoid a cause of grief. Usually, the
1. Denial – A conscious or unconscious negotiation for an extended life is
decision to refuse to admit that made in exchange for a reformed
something is true. Several forms of lifestyle. People facing less serious
denial exist, including denial of fact, trauma can bargain or seek
impact, awareness, cycle , and compromise.
denial.

- I just want to see my daughter’s

graduation then I’ll be ready…”
- Seeks to bargain to avoid loss
- Client (or family) asks for more
time to reach an important life
event and may make
4. Depression – During the fourth Body System Indicator of Imminent
stage, the individual despairs at the Death
recognition of their mortality. In this 1. Cognition/Orientation
state, the individual may become  May be agitated or restless
silent, refuse visitors and spend  Cannot subjectively respond to
much of the time mournful and verbal stimuli
sullen. 2. Cardiovascular
 Tachycardia, irregular heart rate
 Low blood pressure or significant
widening between systolic and
diastolic pressures
 Dehydration
3. Pulmonary
 Tachypnea, dyspnea
 Acetone breath
 Cheyne-stokes breathing
- “I just don’t know how my wife
 Pooling of secretions, or noisy
gets along after I’m gone.”
respirations
- Grieves over what has happened
4. Gastrointestinal
and what cannot be.
 Diminished appetite
5. Acceptance – in this last stage,  Smaller amount of feces
individuals embrace mortality or  incontinence
inevitable future, or that of a loved 5. Renal
one, or another tragic event. People  Diminished urine output
dying may precede the survivors in  Incontinence
this state, which typically comes with  Concentrated urine
a calm, retrospective view for the 6. Mobility
individual, and a stable condition of  Limited mobility
emotions.  Bedbound

Death and Its Definition

 Traditional View: “Heart-lung death”
 Cessation of the apical pulse,
respiration, and blood pressure
 Cerebral death/Higher Brain Death
o Absence of responsiveness
o Absence of cephalic reflexes
o Apnea
o Isoelectric encephalogram
 According to World Medical
- Comes to terms with loss
Assembly, death is:
- May have decreased interest in
o Total lack of response to
surroundings and support external stimuli
persons o No muscular movement
- May wish to begin making plans
o No reflexes
o Flat encephalogram

Development of the concept of death

1. Infancy – 5 years old
• does not understand concept of
death
 • infant’s sense of separation Physiologic Changes
forms basis for later  Rigor Mortis
understanding of loss/death
• believes is irreversible, a
temporary departure or sleep
• emphasize immobility and
inactivity as attributes of death
2. 5-9 years old
 understands that death is final
 believes own death can be
avoided
 associates death with
aggression/violence
3. 9-12 years old o Stiffening of the body OCCURS
 understand death as the ABOUT 2 TO 4 HOURS after
death
inevitable end of life
o Starts in the involuntary muscle
 begins to understand own
mortality, expressed an interest
 Algor Mortis
in afterlife or as fear of death
o Gradual decrease of
 expresses idea about death temperature after death
gathered from parents or older o Due to termination of blood flow
adults to the hypothalamus
4. 12-18 years old o Drop of 1° Celsius per hour
 fears a lingering death o Skin losses elasticity
 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
5. 18-45 years old
 has attitude towards death
influenced by religious or cultural
beliefs
6. 45-65 years old  Livor Mortis
 accept own mortality o Discoloration of tissues
 encounters death of parents or o Appears in the lowermost,
peers dependent areas of the body
 experiences peak of death
anxiety
 death anxiety diminishes with
emotional wellbeing
7. 65 years and above
 fears prolonged illness
 encounters death of family or
peers
 sees death as having multiple
meanings