Tissue Integrity
Sensory Perception
Fundamental Concepts

Nurse will collect urine for a 24 hr. period

What is a timed urine specimen?


They are eaten in large amounts, the primary building blocks of any diet, and provide the body with energy to function

What are macronutrients?


Drainage that is yellow, tan, green, has a bad odor and is a result of infection.

What is purulent drainage?


Leakage and blockage of retinal blood vessels, which can lead to retinal hypoxia, retinal hemorrhages, and blindness

What is diabetic retinopathy?


Airway, breathing, circulation, disability, exposure. Used to prioritize nursing assessment. 

What is ABCDE?


Interventions include a high-fiber diet, staying well hydrated, exercise, bowel training, and medications to soften stools

What are the nursing actions for constipation?


Total Carbs – (minus) Fiber – Sugar alcohol

What are net carbs?


Assess the appearance of the wound, measure the wound (including any tunneling or undermining), note and discharge/drainage, pain, the wound closure, and the status of any drains or tubes.

What is a skin assessment?


An alteration in the middle ear that blocks sound waves before they reach the cochlea of the inner ear.

What is conductive hearing loss?


Location- Where is the pain? Does it radiate anywhere else?

Quality- How does the pain feel?

Intensity- use a scale to determine the level patient is experiencing (number rating, visual analog- Faces)

Timing- onset, duration, and frequency

Setting- How does affect ADL’s

associated  findings- What other symptoms comes with the pain (nausea, fatigue, anger, anxiety, restlessness)

aggravated/ relieving factors- What makes the pain better? Worse?

What is a focused pain assessment?


Describe their frequency of urinations and any associated problems.

Assess use of prescription and OTC meds that affect elimination. 

What is part of the client interview pertaining to urination elimination?


Hair that is dry or brittle, or skin that has dry patches. Poor wound healing or sores. Lack of subcutaneous fat or muscle wasting

What are the findings associated with malnutrition?


 Full-thickness, visible adipose tissue with possible granulation, some slough and eschar present, no exposed muscle or bones.

What is a stage 3 pressure injury?


Provide meaningful stimuli: provide large-print materials, amplify phones, provide pleasant aromas, ensure client has vision and hearing assistive devices, encourage family to bring flowers, sculptures, pictures, or pets when allowed

 What are nursing interventions for sensory deprivation?


diet, exercise, smoking, stress, environmental factors (pollution generated by factories, second-hand smoking)

What are modifiable risk factors associated with alterations in oxygenation?

​​​​Less than 30ml/hr,Dark amber, red, or orange colored Cloudy and/ or thick Glucose and/ or Ketones are present Has an offensive odor

What are abnormal findings in a urinalysis?


Sedentary lifestyle, ethnicity, lack of physical activity, lack of sleep, oversize food portions

What are the risk factors for obesity?


The use of foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing placed for negative pressure that aids in tissue generation, decreasing swelling, and enhances healing in a moist protected environment. 

 What is a vacuum-assisted closure system (wound vac)?


The patient is laying supine and flexes the head to the chest, the hips and knees flex upward (can be noted with meningitis).

What is a positive Brudzinski sign?


Verify placement and patency of IV before administration 

Never infuse medication through tubing that is infusing blood or blood products, or nutrional solutions 

Use an infusion pump to administer medications that are set to run over a period of time and/ or  has serious adverse reactions

Verify compatibility of of medication with other medications or solutions 

What are safety guidelines for IV medication administration?

Female anatomy, Obesity, Physiological changes of aging, Immobility Medications, Neurologic disorders, Confusion, dementia, depression, History of multiple pregnancies and vaginal births
  1. What are risk factors for incontinence?


Verify initial tube placement with an x-ray before initial use, check tube placement every 4 hrs by checking pH of gastric contents,  check the client’s tube feeding tolerance every 4 hrs by measuring the residual, Maintain HOB at 30-45◦

What are priority nursing actions for enteral nutrition?


Encourage an intake of at least 2,500 mL/day of fluid, provide education about good sources of protein (meat, fish, poultry, nuts), provide nutritional support (vitamin and mineral supplements), note if blood albumin levels are low (below 3.5 d/dL), perform wound cleansing and irrigation.

What are nursing interventions to promote wound healing?


Signs include headaches, weakness, visual disturbances, behavioral changes, changes in vital sign, and abnormal breathing patterns.

What are indications for a neuro assessment on children for ICP?


Care provider, case manager, researcher, educator, leader, manager, and change agent

What are responsibilities associated with the nursing role?