Nutrition
703 X weight (lbs)/height2 (in)
What is BMI ?
Responsible for elimination and the production of urine.
What is the kidney?
Serous, sanguinous, serosanguinous drainage
What are characteristics of wound drainage( excudate) ?
Ensure the client wears their hearing aids.
Use a sign language interpreter.
Communicate using paper and pen.
Face the client when speaking
What is communicating with a client with sensory deprivation?
Discharge planning for patient begins....
What is Admissions?
Fruits, beans, veggies, wheat and bran are good a sources of ..
What is fiber?
The nurse identifies a patient has not had a bowel movement in 6 days this is what kind of altered elimination pattern?
What is constipation?
Intact, nonblistered skin with nonblanchable erythema in the area that has been exposed to pressure. Usually bony prominence
What is a Stage 1 pressure injury?
Occurs in older adults:
Loss of ability to focus on close objects
Loss of elasticity and diminishing transparency of the lens.
What is Presbyopia
The nurse educates that the aging process is most likely to cause?
What is hearing loss?
Vitamin K is naturally produced in
What is the large intestine?
A nurse identifies these goups to be at an increased risk for alteration in urinary elimination.
Who are uncircumcised infants,school-aged children
older adults patients?
non-blanchable erythema
amount and depth of skin/tissue loss
presence of dead tissue
tunneling
undermining
condition of tissue
What are assessment findings of wound/ pressure injury?
Head arched back, arms extended by the sides and rotated internally, legs extended and rotated internally, patient rigid with clenched teeth
What is decerebrate positioning?
Your patients feet drags behind them when they walk.
What is foot drop?
This will verify and confirm proper placement of new/initial NG tube.
What is an x-ray?
Urinary retention, incomplete bladder emptying = involuntary urine leakage once the bladder is full (it overflows).
What is overflow incontinence?
Score 6 on Braden Scale
What score indicates a patient is at high risk for alterations in skin integrity?
A POSITIVE sign can be noted with MENINGITIS
= When the patient’s head is flexed, the hips and knees should not flex upward.
ASSESSMENT : Ask the patient to lay supine and flex the head to the chest
What is Brudzinski sign?
Report that must be completed with a fall and or a medication error?
What is an Incedent Report?
Verifying proper placement of NG tube prior to enternal feeding.
What is the HIGHEST priority nursing assessment prior to enternal feeding?
A reagent strip used with urinalysis can detect substances that are consistent with
What is diabetes?
Full-thickness skin loss with visible adipose tissue
What is a stage 3 pressure injury?
A nurse has assessed data that cleint is experiencing vision or hearing loss.
What is sensory deprivation?
This lab value can affect the contractibilty of the heart, indicating a patient is at risk for developing dysrhythemias.
What is Potassium above below 3.5mEq/L or above 5mEq/L