Fundamentals of Nursing: Unit 3 Exam Flashcards


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1

Obtaining a Nasal Swab

explain procedure, check specimen label with pt identification bracelet, assemble equipment, provide privacy, put on goggles, mask, gloves, raise bed, tilt pt head slightly back, open swab kit, remove swab without contaminating, insert swab 2 cm into one naris and rotate for 3 secs or 5 rotations and keep in place for 15 secs, repeat in second nostril, place label on collection tube, put in biohazard bag

2

Obtaining a Nasopharyngeal Swab

ask pt to cough into tissue and tilt head back, open swab, remove swab without contaminating, inspect the back of pt throat using the tongue depressor, insert swab straight back into the nostril aiming along the floor of the nasal cavity, insert approx 6 inches to the posterior wall of the nasopharynx, rotate swab, leave in for 15-30 secs, label collection tube and put in biohazard bag

3

Sputum specimen for culture

place pt in semi fowlers, have pt clear nose and throat and rinse mouth with water, avoid spitting, instructions pt to inhale deeply 2 or 3 times and cough with exhalation (splint abdomen if they have had abdominal surgery), expectorate specimen into container, offer oral hygiene, label and put in biohazard bag

4

Urine specimen clean catch/midstream

have pt perform hand hygiene, do not defecate or discard toilet paper into urine, separate labia for cleaning of the area, female pt should use towelettes or wet washcloth to clean each side of the urinary meatus, then the center over the meatus, from front to back, using new area of washcloth with each stroke, keep labia separated after and cleaning and during collection, males should use towelette to clean the area around the meatus of the penis wiping in a circular motion away from the urethral meatus, uncircumcised male pt to retract the foreskin before cleaning and during collection, do not let container touch hair or skin, have pt void small amount of urine, pt then should stop urinating briefly and then continue voiding into the collection cup 3-5 mL, provide perineal care if necessary, label put in biohazard bag, transport specimen to lab asap, refrigerate if needed

5

Can you delegate a urine specimen by midstream to a NAP or UPA

Yes

6

Urine specimen indwelling catheter

clamp catheter drainage tubing, scrub aspiration port vigorously with alcohol, allow port to air dry, attach syringe to the port, slowly aspirate urine 3-5 mL, remove syringe, unclamp drainage tube, slowly inject urine into specimen container, label and put into biohazard bag, get to lab asap or refrigerate it

7

Can UPA or NAP obtain urine specimen from an indwelling catheter

yes

8

Testing stool for occult blood using gFOBT

open flap on sample side of card, with wooden applicator apply a small amount of stool from the center of the bowel movement onto the window of testing card, repeat using other side of wooden applicator from a new area of stool, close flaps wait 3-5 mins before developing, open flap on opposite side of card and place two drops of developer over each window, observe for blue areas, blue indicates positive

9

Should you turn your back to something sterile?

No.

10

PERRLA

pupils equal, round, reactive to light and accommodation

11

Rombergs test

standing up with eyes closed to see if they keep balance

12

Catheter bag should be kept

below the level of the bladder

13

Infection

is a disease state that results from the presence of pathogens

14

Pathogen

An organism that causes disease

15

Infection cycle

infectious agent, reservoir, portal of exit, means of transmission, portal of entry, susceptible host

16

The most significant and most commonly observed infection-causing agents in health care

bacteria

17

Smallest of all microorganisms

virus ex. Hepatitis B & C, AIDS

18

Plant like organisms that cause infection

fungi ex. ringworm, yeast infection

19

The ability to cause disease is called

virulence

20

Endemic disease

occurs predictability in one specific region or population ex. Malaria

21

Infectous agent

a pathogen that can cause infection ex. bacteria, virus, fungi, parasite

22

Reservoir

for growth and multiplication of microorganisms the natural habitat of the organisms. ex. people, animals, soil, food, water, milk, and inanimate objects

23

Portal of exit from reservoir

point of escape for the organisms from the reservoir ex. respiratory, gastrointestinal, and genitourinary tracts, as well as breaks in the skin

24

Means of transmission

how infectious microorganisms move to another location ex. direct and indirect contact, droplet, airborne

25

Direct contact transmission

requires close proximity between the susceptible host and an infected person or carrier ex. touching, kissing, sexual intercourse

26

Indirect contact transmission

involves personal contact with either a vector or famine

27

What is a vector?

a living creature that transmits an infectious agent to a human usually an insect

28

What is a fomite?

inanimate object. equipment or countertops

29

Antimicrobial

agent that kills microorganisms

30

Droplet transmission

greater than 5 mcm, sneezing, coughing, talking

31

Airborne transmission

less than 5 mcm sneezing, coughing

32

Examples of contact diseases

E. coli, Hepatitis B, HIV, Salmonella, Staphylococcus aureus

33

Examples of airborne diseases

TB, measles, chicken pox (varicella), Herpes zoster

34

Examples of droplet disease

rubella, mumps, diphtheria

35

Portal of entry

a way for the causative agent to enter a new reservoir or host. may be the same as portal of exit skin, urinary, respiratory, and gastrointestinal tracts

36

Susceptible host

a person likely to get an infection or disease immunocompromised, breaks in the skin

37

Stages of infection

Incubation period/Prodromal stage/Full (acute) stage of illness/Convalescent period

38

Prodromal stage

a person is most infectious during this stage early signs and symptoms of disease are present but are often vague and nonspecific (fatigue to malaise to a low grade fever) last from several hours to several days unaware of being contagious

39

Incubation period

interval between the pathogens invasion of the body and the appearance of symptoms of infection organisms are growing and multiplying length of incubation may vary

40

Full stage of illness

the presence of infection-specific signs and symptoms indicates the full stage of illness. type of infection determines the length and severity of the manifestations

41

Symptoms that are limited or occur in only one body area

localized symptoms

42

Symptoms manifested throughout the entire body

systemic symptoms

43

Convalescent period

recovery from the infection may vary according to the severity of the infection and the patients general condition signs and symptoms disappear and the person returns to a healthy state depending on infection may cause permanent damage or change to a persons health

44

Inflammatory response

protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur

45

Signs of acute infection

redness, heat, swelling, pain, loss of function

46

Immune response

The body's defensive reaction to invasion by bacteria, viral agents, or other foreign substances.

47

Native immunity

Restricts entry or immediately responds to a foreign organism

48

Passive immunity

antibodies are produced by an external source

49

Factors affecting the risk for infection

1. Integrity of skin and mucus membranes 2. pH levels 3. Integrity and number of WBCs 4. Age, sex, race, heredity 5. Immunizations 6. General health status 7. Stress level 8. Use of invasive devices

50

5 moments of hand hygiene

1) before touching patient 2) before clean/aseptic procedure 3) after body fluid exposure risk 4) after touching patient 5) after touching patient surroundings

51

Medial asepsis

clean technique, involves procedures and practices that reduce the number and transfer of pathogens, hand hygiene and wearing gloves

52

Surgical asepsis

sterile technique, practices used to render and keep objects and areas free from microorganisms, inserting indwelling catheter or IV catheter

53

What is the most effective way to help prevent the spread of infectious agents?

hand hygiene

54

What is a health-care associated infection? (HAIs)

infections that a client acquires while receiving care in a health care setting.

55

If hands are not visibly soiled

use alcohol based hand rub

56

If hands are visibly soiled

wash with soap and water

57

Does alcohol kill C. Diff spores?

No. Use soap and water

58

How long do you wash your hands?

20 seconds scrub longer for visible soiled hands

59

When should you wash your hands?

1. before and after touching a resident 2. after using the toilet 3. when arriving to work 4. before and after gloving 5. after touching contaminated items 6. after nose-blowing, sneezing or coughing 7. before and after eating

60

An infection is exogenous when

the causative organism comes from other people

61

An infection is endogenous when

the causative organism comes from microbial life harbored in the person

62

An infection is iatrogenic when

it results from a treatment of diagnostic procedure

63

Catheter-associated urinary tract infection

CAUTI

64

surgical site infection

ssi

65

central line associated bloodstream infection

clabsi

66

Ventilator associated pneumonia

VAP

67

multidrug-resistant organisms (MDRO)

responsible for majority of HAIs

68

Used to treat MRSA

vancomycin and linezolid

69

VRSA is resistant to what?

vancomycin

70

disinfection

destroys all pathogenic organisms except spores

Used when cleaning the skin for a procedure or cleaning a piece of equipment that does not enter body part

71

VAP is responsible for

majority of HAIs

72

Personal Protective Equipment (PPE)

gloves, gowns, masks, and protective eye gear

73

Gloves are not a good substitute for good hand hygiene

True or False

true

74

Standard Precautions (tier 1)

used on all patients regardless of their diagnosis

75

Transmission-based precautions (tier 2)

precautions used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes

76

Three types of transmission based precautions

airborne, droplet, contact

77

Airborne precautions

private room with negative air pressure

6-12 air changes per hour

keep door closed

pt must wear surgical mask if leaving room

78

Droplet precautions

private room if available, door may be open

PPE upon entering room for all interactions that may involve contact with pt

pt must wear surgical mask if possible

keep visitors 3 ft from infected person

79

Contact precautions

private room if available

wear PPE whenever you enter room and take off before exiting room

limit movement of pt out of room

avoid sharing patient-care equipment

80

Donning PPE

  1. gown
  2. mask
  3. goggles
  4. gloves
81

Doffing PPE

Doffing PPE

  1. gloves
  2. gown
  3. mask
  4. goggles
82

Airborne precautions PPE

N95 respirator, gown, gloves, goggles

83

Droplet precautions PPE

surgical mask, gown, gloves, goggles

84

Contact precautions PPE

gown and gloves

85

Testing pupillary response to light and accommodation assesses which cranial nerve

cranial nerve III, the oculomotor nerve

86

Pupils are normally

black, equal in size, round, and smooth

87

The normal and consensual pupillary response is

constriction

88

The pt following your finger or penlight with the eyes as you move through the six cardinal positions of gaze evaluates the function of what

this evaluates the function of each of the extraocular eye muscles (EOM) and test cranial nerves III, IV, VI (oculomotor, trochlear, and abducens nerves) normally, both eyes move together, are coordinated, and are parallel

89

Testing the pt visual acuity with a Snellen chart evaluates what

this evaluates the patients distance vision and function of cranial nerve II (optic nerve)

90

Using a whisper test evaluates what

provides a gross assessment of cranial nerve VIII (acoustic nerve)

the patient should repeat what was said

91

Asking the pt to stick out the tongue and inspecting evaluates what

evaluates the function of cranial nerve XII (hypoglossal nerve)

92

Cranial Nerve I: Olfactory

sensory, smell

test sense of smell in both nostrils

93

Cranial Nerve II: Optic

sensory, vision

snellen chart

94

Cranial Nerve III: Oculomotor

motor, eye movement

EOM and pupil construction

cardinal fileds, PERRLA

95

Cranial Nerve IV: Trochlear

motor, moves eye

cardinal fileds, PERRLA

96

Cranial Nerve V: Trigeminal

both, face sensation, mastication

have pt close eyes and check sensation on both sides of the face- light dull sharp

move jaw from side to side

97

Cranial Nerve VI: Abducens

motor, abducts the eye

cardial fileds, PERRLA

98

Cranial Nerve VII: Facial

both, facial expression, taste

stick out tongue

frown, show teeth, smile

99

Cranial Nerve VIII: Vestibulocochlear Auditory

sensory, hearing and balance

100

whisper test

webber, rinne, Romberg

101

Cranial Nerve IX: Glossopharyngeal

both, taste, gag reflex

talk, swallow, cough

say ah

102

Cranial Nerve X: Vagus

both, gag reflex, parasympathetic innervation

103

Cranial Nerve XI: Accessory or Spinal

motor, shoulder shrug

shrug shoulder, turn head against resistance

104

Cranial Nerve XII: Hypoglossal

motor, swallowing, speech

stick out tongue and move from side to side

105

What is safety?

freedom from danger, harm or risk

106

Glasgow Coma Scale

measures level of consciousness

107

Romberg test

ask client to stand with feet at comfortable distance apart, arms at sides, and eyes close

108

Webber test

Tunning fork on midline of skull, pt idenities sound that is loudest, normal hearing sound is heard equally, sound louder in ear with hearing loss, softer in ear with sensorineural hearing loss.

109

Rinne test

hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction

110

Level of Consciousness (LOC) is described as what?

awake and alert

stuporous

comatose

111

Functions: swallowing and speaking

Vagus

112

What are components of Glasgow Coma Scale?

eye opening, verbal response, motor response

113

Functions: face sensation, jaw movement from side to side

Trigeminal

114

Functions: pupil constriction

assess for dropping eyelids, Oculomotor

115

Functions: hearing

Auditory

116

Functions: shoulder shrug

Accessory

117

Functions: movement of the face muscles

Facial

118

Functions: smell

Olfactory

119

Functions: vision

Optic

120

drug's brand name

trade name, selected by pharmaceutical company

121

generic name

identifies active ingredient, assigned by the manufacturer that first develops the drug

122

intradermal

into the dermis

123

tb testing or allergy

5-15 degrees

124

Intramuscular

into the muscle 90 degrees

125

Intravenous

into a vein

126

subcutaneous

into adipose tissue heparin and insulin 45 or 90 degrees

127

information on a medication label

1. Storage Directions 2. Lot/Control number- need for vaccine 3. National Drug Code (NDC)- 4. Manufacturer's name- need for vaccine 5. Controlled substance 6. National List of Approved Medicines USP - United States Pharmacopoeia NF- National Formulary

128

A verbal order should contain

the same information as a written order

129

Factors that affect safety

Developmental level, lifestyle, mobility, sensory perception, knowledge level, communication ability, physical health state, and psychosocial state

130

Preventing falls in the home

installing hand rails, ensure good lighting, discarding or repairing broken equipment, remove rugs

131

Reconstitute

add liquid to a powered medication

132

Subcutaneous

under the skin

133

scored tablet

may be broken into equal parts

134

Entric-coated tablet

cannot be broken

135

Oral medications

Solid form: tablets, capsules, pills Liquid form: elixirs, spirits, suspensions, syrups

136

Topical medications

Medicine applied to the skin.

137

Otic medications

administered into the ear adults: up and back children: down and back

138

Transdermal medication

administered from a patch that is applied to unbroken skin

139

Restraints

must be last option least restrictive restraint should be the first option patients family must be involved pt must be assessed every 2 hrs new orders need to be written and examined by doctor every 24 hrs

140

Rights of Medication Administration

Right medication Right patient Right dosage Right route Right time Right reason Right assessment data Right documentation Right response Right to education Right to refuse

141

Before giving a medication check for how may identifiers?

two full name and another one

142

1+ pitting edema

2mm slight indentation

143

2+ pitting edema

4mm deeper pit after pressing

144

3+ pitting edema

6mm deep pit remains several seconds after pressing skin swelling obvious

145

4+ pitting edema

8mm deep pit remains for prolonged time after pressing, possibly minutes

146

Macule

flat and colored, smaller than 1cm ex. freckles and petechiae

147

Papule

elevated and raised, but superficial. tiny raised bump on skin

148

Vesicle

elevated and filled with serous fluid ex. blister, herpes simplex, varicella

149

Nodule

palpable, circumscribed, deep, firm ex. Wart

150

Pustule

pus filled ex. Acne

151

Wheal

insect bite

152

Tumor

solid mass larger than 1-2 cm ex. epithelioma Excoriation Superficial scratching, skin picking

153

Erosion

loss of epidermis, moist surface, no bleeding ex. ruptured vesicle

154

Fissure

linear break in the skin ex. tinea pedis

155

Ulcer

irregular shape, loss of tissue ex. pressure ulcer

156

Crust

dried blood, serum, or pus ex. Scab

157

Braden Scale

identifies person at risk for pressure injuries the lower the score the more at risk they are

158

Alopecia

hair loss

159

Hirsutism

excessive hair growth

160

clubbing of nails

finding in the nails that indicates chronic hypoxia

161

RACE stands for what?

rescue, activate, confine, evacuate

162

Never events

medical errors that should never occur

163

Needle Safety

Needles are to be used only once. Used needles must never be re-used. Used needles should never be re-capped, broken or bent. Used needles must be disposed of in a puncture-resistant Sharps container. If blood is not obtained on the first attempt, a new needle must be used every for subsequent attempts.

164

What is the largest organ of the body and has multiple functions?

Skin

165

Epidermis

the top layer, or outermost portion

166

Dermis

the second layer of the skin

167

subcutaneous tissue

Tissue, largely fat, that lies directly under the dermis and serves as an insulator of the body.

168

Functions of the skin

protection, temperature regulation, psychosocial, sensation, vitamin D production, immunologic, absorption, and elimination

169

Wound

break or disruption in the normal integrity of the skin and tissues

170

Open wound

skin surface is broken

171

Closed wound

results from a blow, force, or strain caused by trauma such as a fall, an assault, or motor vehicle crash

172

Acute wounds

such as surgical incisions, usually heal within days to weeks. The wound edges are well approximated (edges meet to close skin surface) and the risk of infection is lessened. Acute wounds usually move through the healing process without difficulty.

173

Chronic wounds

include any wound that does not heal along the expected continuum, such as wounds related to diabetes, arterial or venous insufficiency, and pressure injuries

174

Four phases for wound healing

Hemostasis Inflammation Proliferation Maturation

175

Hemostasis

Occurs immediately after initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering

176

Exudate

fluid, such as pus, that leaks out of an infected wound causes pain and swelling

177

Inflammatory phase

last 2-3 days, white blood cells, predominantly leukocytes and macrophages, move to the wound. pt has a generalized body response including a mildly elevated temp, leukocytosis, and general malaise

178

Proliferation phase

last for several weeks, new tissue is built

179

Maturation phase

final stage (remodeling) begins about 3 weeks after injury, possible to continue for months or years

180

Desiccation

dehydration, causes a crust to form over wound site and delays healing

181

Pressure

disrupts the blood supply to the wound area, interfere with blood flow and delays healing

182

Maceration

over hydration, softening and breakdown of skin, results from prolonged exposure to moisture

183

Trauma

results in delayed healing or the inability to heal

184

Edema

swelling, interfere with blood supply, results in inadequate supply of oxygen and nutrients to the tissue

185

Excessive bleeding

results in large clots. Large clots increase the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue. In addition, accumulated blood is an excellent place for growth of bacteria and promotes infection

186

Necrosis

dead tissue, appears as slough moist, yellow, stringy tissue

187

Eschar

dry, black, leathery tissue

188

Biofilm

bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins

189

Wound infection

pt immune system fails to control the growth of microorganisms

190

Hemorrhage

excessive bleeding, may occur from a slipped suture, dislodged clot at wound site, infection, erosion of a blood vessel by a foreign body

191

Hematoma

internal hemorrhage, localized mass of usually clotted blood

192

Ischemia

deficiency of blood to an area

193

Dehiscence

partial or total separation of wound layers

194

Evisceration

the most serious complication of dehiscence. primarily occurs with abdominal incisions. wound completely separates (protruding bowel) at risk include: obese, malnourished, smokers, anticoagulants, infected wounds, excessive coughing, vomiting, straining

195

Fistula

abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another ex. abnormal connection between the rectum and vagina

196

Abscess

collected of infected fluid that is not drained

197

Pressure injury

localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device

198

Friction

two surfaces rub against each other

199

Shear

results when one layer of tissues slides over another layer, separates the skin from underlying tissues

200

Pressure injury stage 1

intact skin , redness over bony prominence. nonblanchable erythema of intact skin

201

Pressure injury stage 2

partial thickness skin loss with exposed dermis, wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Blister Adipose (fat) and deeper tissue is not visible

202

Pressure injury stage 3

full thickness skin loss, adipose (fat) is visible, rolled wound edges, slough and eschar may be visible, depth of tissue damage varies by anatomical location, undermining and tunneling may occur cannot see bone or tendon

203

If slough or eschar obscures the extent of tissue loss this is an

unstageable pressure injury

204

Pressure injury stage 4

full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. exposed bone or tendon Unstageable pressure injury, obscured full-thickness skin and tissue loss in which the extend of tissue damage within the ulcer cannot be confirmed bc it is obscured by slough or eschar. cannot see base of wound

205

If slough or eschar is removed from an unstageable pressure injury

what will be revealed?, a stage 3 or stage 4 pressure injury will be revealed

206

Deep tissue pressure injury

persistent non-blanchable deep red, maroon, or purple discoloration

207

measuring wounds and pressure injury

size of wound: draw the shape and describe it, measure the length, width, and diameter depth of wound: moisten a sterile, flexible applicator with saline and insert it gently into wound at a 90 degree angle, mark point on swab where it is even with skin, remove swab and measure depth with ruler wound tunneling: determine direction and depth

208

Can you back stage a pressure injury?

NO

209

Serous drainage

clear and watery

210

Sanguineous drainage

looks like blood

211

Serosanguineous drainage

serum and blood

212

Purulent drainage

thick, often has a musty or foul odor and varies in color (dark yellow or green)

213

Purosanguineous drainage

mixed drainage of pus and blood

214

Primary intention healing

little or no tissue loss edges approximated, as with a surgical incison heals rapidly low risk of infection no or minimal scarring ex. closed surgical incision with staples, sutures, or liquid glue to seal laceration

215

Secondary intention healing

loss of tissue wound edges widely separated, unapproximated (pressure injury, open burn areas) longer healing time increase risk for infection scarring heals by granulation ex. pressure injury left open to heal

216

Tertiary intention healing

widely separated deep spontaneous opening of a previously closed wound closure of wounds occur when they are free of infection and edema risk of infection extensive drainage and tissue debris closed later longer healing time ex. abdominal wound initially left open until infection is resolved and then closed

217

Preventing Pressure Injuries

-Assess the skin of patients at risk on a daily basis. Pay particular attention to bony prominences. -Cleanse the skin routinely and whenever any soiling occurs. Use a mild cleansing agent, minimal friction, and avoid hot water. -Maintain higher humidity in the environment and use skin moisturizers for dry skin. -Avoid massage over bony prominences. -Protect the skin from moisture associated with episodes of incontinence or exposure to wound drainage. -Minimize skin injury from friction and shearing forces by using proper positioning, turning, and transferring techniques. Use lubricants, protective films, dressings, and padding to diminish the effects of friction on the skin. -Use appropriate support surfaces (tissue load management surfaces). -Investigate reasons for inadequate dietary intake of protein and calories. Administer nutritional supplements or more aggressive nutritional intervention as needed. -Continue efforts to improve mobility and activity. If this is unrealistic, attempt to maintain current level of activity, mobility, and range of motion. -Document measures used to prevent pressure ulcers and the results of these interventions.

218

Cleaning wounds with approximated edges

- Use standard precautions - Moisten a sterile gauze pad or swab with the prescribed cleansing agent - Use a new swab or gauze for each downward stroke - Clean from top to bottom - Work outward from the incision in lines parallel to the wound - Wipe from the clean area toward the less clean area

219

Cleaning wounds with unapproximated edges

- Use standard precautions - Moisten a sterile gauze pad or swab with the prescribed cleansing agent - use a new swab or gauze for each CIRCLE - Clean the wound in full or half circles, beginning in the center and workin toward the outside - If a dressing is not being applied, clean to at least 2 inches beyond the wound margins

220

Penrose drain (open drainage system)

soft and flexible, empties into absorptive dressing material. (abdomen)

221

Closed drainage system

-Jackson-pratt drain -Hemovac drain may be connected to an electrical suction or built-in reservoir

222

Jackson-Pratt (JP)

A disposable suction device that is connected to a drain that is inserted into or close to a surgical wound.

223

Hemovacs

placed under skin during surgery removes blood or other fluids that might build up (knee and abdomen)

224

Applying cold

30 mins on and 1 hr off

225

T-tube drain

used after gallbladder surgery Placed in common bile duct to allow passage of bile collects bile

226

Applying heat

20 minutes

227

suture and staple removal

sterile technique clean from inside out remove every other one

228

Collection of urine and stool can be delegated to a UAP? true or false

true

229

24 hr urine collection

-discard first void, collect all urine for 24 hrs -do not allow contamination of stool -keep urine on ice/fridge -end on empty bladder UAP can help

230

Dehiscence require emergency treatment

call for help, notify provider stay with client cover the wounds with sterile towels or dressings soaked with sterile normal saline solution do not attempt to reinsert the organs position client supine with hips and knees bent observe for shock maintain calm environment keep client NPO

231

Replacement with identical cells

Regeneration

232

Well approximated

intentional wounds with minimal tissue loss, primary intention

233

wounds are not well approximated

large open wounds from burns or major trauma, surgical wounds that are left to heal without closure, primary intention wounds that become infected, take longer to heal and form more scar tissue, secondary intention

234

delayed primary closure

wounds left open for several days to allow edema or infection to resolve or fluid to drain, then are closed, tertiary intention