Tissue Integrity
Sensory Perception
Fundamental Concepts

A condition commonly found in older patients and can impact nutrition. Characterized by a dry mouth and lack of saliva. 

What is Xerostomia?

This condition is common in older pts as saliva production decreases. Can also be caused by dehydration and certain medications.


The Two Types of Elimination 

What is Bowel and Urinary Elimination?


A nursing tool used to identify patients at high risk for pressure injury development; categories of evaluation include sensory perception, moisture, activity, mobility, nutrition, friction, and shear.  

What is the Braden Scale?


Presbyopia, cataracts, glaucoma, diabetic retinopathy, macular degeneration, infection, inflammation, injury, brain tumor

What are vision loss causes?


Addresses the needs of healthy clients to promote health and prevent disease with specific protections. i.e.immunizations

What is primary prevention?


> Confirm Placement with X-Ray                               > Aspirate fluid from the NG tube with a syringe. Confirm the pH of the fluid, should be below 5.

What is How to Confirm NG Tube Placement?


When urine is voided without warning or there is a lack of urgency/ feeling. This affliction is common in pts with multiple sclerosis or spinal cord injuries. 

What is Reflex incontinence?


Damage in the wound bed cannot be observed due to slough and eschar covering the wound.                  Once the eschar and slough is removed, full-thickness skin loss will be revealed. Possible that adipose or bone is visible. 

What is Unstageable Pressure Injury 


This disease interferes with the peripheral nerves. Manifests symptoms such as aching, shooting pain, and imbalance.

What is peripheral neuropathy?


Health assessment that fosters communication and creates an environment that promotes an optimal health assessment/data collection experience

What is therapeutic communication?


Changes in global nutrition trends lead to increased consumption of fats, refined sugars, and grains. Disease prevalence is linked to genetic and social factors. Health behaviors are greatly influenced by parental figures, with children of afflicted pts more likely to experience disease occurrence. Socioeconomic factors greatly impact access and quality of foods impacting disease outcomes.  

What is Risk Factors for Obesity?


A nursing intervention that can identify diseases—such as bladder infections (UTIs), Diabetes, kidney infections, and disease—from a patient's urine.

What is a Urinalysis?


This layer insulates the body, absorbs shock, and pads the internal organs and structures. Also contains blood vessels and nerves that assist in thermoregulation and sensation

What is the subcutaneous layer?


These medications are toxic to the ear and include Gentamicin, Metronadazole, Fursosemide, NSAIDs, Ciplastin and more

What are ototoxic medications?


Has 3 stages: alarm, resistance, and exhaustion

What is the General adaptation syndrome?(GAS)


BMI (kg/Meters) for a Pt who weighs 140lbs and 5'5 ft.  > State if their BMI is normal, overweight or obese. 

What is 23?

>Normal/Healthy BMI

> BMI = Weight/ Height^2

          140/2.2 = 63.63..

          5'5 / 3.28 = 1.65 -> (1.65^2) = 2.72

          63.63 / 2.72 = 23.39


Characteristic:                                                           > 800-2400 ml/ day >pH: 4.5 - 8 > Light straw to amber yellow > Transparent, clear >Protein: 2–8 mg/dL > Faint, aromatic >Specific gravity: 1.005–1.030 >No microorganisms present  > Glucose & Ketones: not present  > RBC: None  >WBC: 3–4 per low-power field

What is Normal Characteristics of Urine?


Characteristics considered for this nursing intervention include location, stage, and size; a description of the tissue; the color of the wound bed; the condition of the surrounding tissue; the appearance of the wound edges; the presence of undermining and tunneling; and any foul odor present.

What is wound documentation?


Causes restricted blood flow to the brain and receptor organs lead to decreasing awareness and slowed responses

What is atherosclerosis?


The nurses understand and address the entire cultural context of each client within the realm of the care they deliver

What is cultural competency?


Skills required for nursing intervention:                     > Verify Order and Expiration Date                            > Elevate bed 30-40 degrees - prevents aspiration       >Flush tube w/ 30-50 ml of water                              > Disinfect insertion points                                     > Administer via gravity or hung bag  

What is Administering Enteral Nutrition?



>Less than 800 mL  OR A large amount over intake

>Color: Dark amber, Dark orange, Red or dark brown

> Appearance: Cloudy, Mucous plugs, viscous, thick

> Odor: Offensive 

> Microorganisms present

>pH: Greater than 8 or less than 4.5

> Protein: > 8 mg/dl

> Glucose or Ketone: Present 

> RBC and RBC: Present 

What is Abnormal Characteristics of Urine?


Dead tissue and accumulated debris (also called biofilm) are removed with a scalpel or scissors. Also  decreases the number of bacteria in the wound and stimulates wound closure and epithelization.

What is surgical debridement?


Instructions for this nursing intervention include: Place the base of a vibrating tuning fork on the patient’s mastoid bone. Ask the patient to indicate when the sound is no longer heard. When the patient does so, quickly reposition the tuning fork in front of the patient’s ear, close to the ear canal

What is the Rinne Test?

  • Educate family members on potential social isolation, physical demands, and other stressors and on the resources available in the community.
  • Provide short-term care to provide relief for the family caregiver.
  • Provide encouragement during times of stress.
  • Seek congruence among perceived roles.

What is patient centered care(relating to self concept)?