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the ability of body tissues to regenerate and/or repair to
tissue integrity maintain normal physiological processes
interventions to maintain reposition turning adequate nutrition skin assessments
tissue integrity
A test of the rate of capillary refill; blanching means to
blanching test cause to become pale by applying digital pressure.
skins stay very red even with finger pressure; indicates
Non-blanchable severe skin injury
Stage 1 pressure ulcer intact skin with nonblanchable redness
partial thickness skin loss involving epidermis, dermis,
or both
stage 2 pressure ulcer red/pink noist
blister et shallow crater
stage 3 pressure ulcer full thickness tissue loss with visible fat
Full-thickness tissue loss with exposed bone, muscle,
stage 4 pressure ulcer or tendon
Removal of foreign matter or dead tissue from a wound
promotes healing
debridement
a thick layer of dead tissue and tissue fluid that
eschar develops over a deep burn area
Types of drainage serous, sanguineous, serosanguineous, purulent
clear, watery fluid
serous drainage clear yellow
serosanguineous drainage thin, watery drainage that is blood-tinged
sanguineous drainage bloody drainage
purulent drainage thick green, yellow, or brown drainage
Braden Scale A tool for predicting pressure ulcer risk
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The inability to completely digest the milk sugar lactose
lactose intolerance
bloating, abdominal discomfort, diarrhea gas
symptoms of lactose
intolerance
a diet that consists of foods that are liquid at room
temperature and leave little residue in the intestine. Ex:
clear liquid diet Water, Sprite, Ginger Ale, all beverages without any
residue, broth, Jello
red Meat, fish, poultry, legumes. spinach, liver or organ
iron rich foods meat, tofu
An eating disorder characterized by an obstinate and
willful refusal to eat, a distorted body image, and an
anorexia nervosa intense fear of being fat
A refusal to keep one's body weight at or above a
normal weight for age and height; extreme weight loss,
signs of anorexia nervosa muscle wasting, eats very little
insufficient nutrition
common obesity
weight gain/ nutritional toxicity
excessive nutrition excessive calorie intake
FICA spiritual assessment tool
F in FICA faith
I in FICA importance
C in FICA community
A in FICA address
do you attend religious regularly
questions to assess do you have Any spiritual needs we should discuss
spiritual needs in need of spiritual intervention call chaplain
Prayer An attempt to contact God, usually through words
Faith Belief in God
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the ability of body tissues to regenerate and/or repair to
tissue integrity maintain normal physiological processes
interventions to maintain reposition turning adequate nutrition skin assessments
tissue integrity
A test of the rate of capillary refill; blanching means to
blanching test cause to become pale by applying digital pressure.
skins stay very red even with finger pressure; indicates
Non-blanchable severe skin injury
Stage 1 pressure ulcer intact skin with nonblanchable redness
partial thickness skin loss involving epidermis, dermis,
or both
stage 2 pressure ulcer red/pink noist
blister et shallow crater
stage 3 pressure ulcer full thickness tissue loss with visible fat
Full-thickness tissue loss with exposed bone, muscle,
stage 4 pressure ulcer or tendon
Removal of foreign matter or dead tissue from a wound
promotes healing
debridement
a thick layer of dead tissue and tissue fluid that
eschar develops over a deep burn area
Types of drainage serous, sanguineous, serosanguineous, purulent
clear, watery fluid
serous drainage clear yellow
serosanguineous drainage thin, watery drainage that is blood-tinged
sanguineous drainage bloody drainage
purulent drainage thick green, yellow, or brown drainage
Braden Scale A tool for predicting pressure ulcer risk
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The inability to completely digest the milk sugar lactose
lactose intolerance
bloating, abdominal discomfort, diarrhea gas
symptoms of lactose
intolerance
a diet that consists of foods that are liquid at room
temperature and leave little residue in the intestine. Ex:
clear liquid diet Water, Sprite, Ginger Ale, all beverages without any
residue, broth, Jello
red Meat, fish, poultry, legumes. spinach, liver or organ
iron rich foods meat, tofu
An eating disorder characterized by an obstinate and
willful refusal to eat, a distorted body image, and an
anorexia nervosa intense fear of being fat
A refusal to keep one's body weight at or above a
normal weight for age and height; extreme weight loss,
signs of anorexia nervosa muscle wasting, eats very little
insufficient nutrition
common obesity
weight gain/ nutritional toxicity
excessive nutrition excessive calorie intake
FICA spiritual assessment tool
F in FICA faith
I in FICA importance
C in FICA community
A in FICA address
do you attend religious regularly
questions to assess do you have Any spiritual needs we should discuss
spiritual needs in need of spiritual intervention call chaplain
Prayer An attempt to contact God, usually through words
Faith Belief in God
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