Term
| PRE OP ASSESSMENT Health history |
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Definition
| previous surgeries and hospitalizations- date and reason, complications, chronic illnesses, menstrual cycle, medications-rx and OTC |
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Term
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Definition
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Term
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Definition
| electrolyte imbalance, resp depression fron anesthesia |
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Term
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Definition
| increase hypotensive effects of anesthetic agents |
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Term
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Definition
| chest xray, ecg, cbc, electrolyte, urnialysis |
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Term
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Definition
| it is the provider's responsibility to discuss risks and complications |
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Term
| Informed consent protects |
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Definition
| surgeon from unauthorized operations, and protects patient from unsanctioned events |
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Term
| criteria for valid consent |
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Definition
| must be mentally competent, info is provided in vernacular |
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Term
| client is informed of the... |
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Definition
| procedure and risks, benefits and alternatives, be offered an opportunity to answer questions, be ifnormed that they may withdraw consent, and informed of any deviation from normal |
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Term
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Definition
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Term
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Definition
| turn cough deep breathing |
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Term
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Definition
| pause before surgery to assure |
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Term
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Definition
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Term
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Definition
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Term
| you want to use the least amount of.. |
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Definition
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Term
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Definition
| exposure to succyinylcholine/anectine, disruption of normal Ca influx across cell membrane, happens within 10-20 minutes |
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Term
| what happens in malignant hyperthermia? |
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Definition
| muscle ridgity hyperthermia, hypoxemia, lactic acidosis, cardiac arryhtmias, death |
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Term
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Definition
| the period of time from the DECISION of surgery til pt is transferred to operating room |
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Term
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Definition
| period of time from the pt is transferred to OR til admission to PACU |
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Term
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Definition
| period of time that that begins with Admission to PACU and ends with follow up eval in clinical setting or home |
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Term
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Definition
| preparation of pt for surgery, surveying during surgery, preventing complication, facilitating recovery |
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Term
| diagnostic surgery classification |
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Definition
| focused on removal of samples of pt's tissues. biopsy etc |
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Term
| curative surgery classification |
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Definition
| removal of tumor, foreign body, pt may still need chemo/radiation |
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Term
| difference between reparative/reconstructive classification |
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Definition
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Term
| palliative surgery classification |
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Definition
| is a type of surgery that does not treat the underlying disease but is done to control symptoms of cancer, such as pain.. palliative care |
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Term
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Definition
| abrupt withdrawl may cause cardiovascular collapse |
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Term
| antibx in "mycin" group may.. |
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Definition
| respiratory paralysis, when combined with certain muscle relaxants |
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Term
| a risk for iodine allergy may be indicated by.. |
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Definition
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Term
| latex- look at bruner figure 18-2 |
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Definition
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Term
| the elderly need special considerations for surgery bc.. |
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Definition
| decreased organ function, impaired healing, comprehension?, past surgeries, impaired mobility, chronic illness |
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Term
| what are some pre op nursing diagnoses? |
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Definition
| fear, anxiety, knowledge deficit, potential for body image disturbance, anticipatory grieving, pain |
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Term
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Definition
| chart check, take VS, check consent, check history, old records available, and lab values, ID AND ALLERGY BANDS |
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Term
| what sort of products should be readily avaiable for surgery just in case? |
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Definition
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Term
| immediately before operation patient should be.. |
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Definition
| put in gown and cap, no nail polish, preggers test, remove jewelry makeup and bobby pins and false teeth |
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Term
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Definition
| anticholinergics, benzos!, H2 receptor antatgonists, antacids, antiemetics, opioids, antibx, eye drops, insulin |
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Term
| which is an example of a diuretic that has the potention to affect the surgical experience? |
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Definition
| hydrochlorothiazide, can cause excessive respiratory depression from electrolyte imbalance |
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Term
| best anesthesia for an older adult with an inguinal hernia repair? |
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Definition
| D. regional anesthesia. reduces pain, bowel dysfunction, and length of hospital stay for older adult pts |
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Term
| malignant hyperthermia occurs how long after induction of anesthesia?? |
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Definition
| 10-20 minutes.. it can also occur during the first 24 hours after surgery |
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Term
| Which phase of the surgical experience encompasses the period of time from when the patient is transferred to the operating room to the time of admission to the postanesthesia care unit (PACU)? |
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Definition
| intraoperative, begins with pt on or table til admission to the PACU |
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Term
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Definition
| VS q 15 minutes, circulatory/cv - assess rhythm rate and quality. |
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Term
| decreased pulse rate/quality in PACU may mean.. |
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Definition
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Term
| PACU pt care for airway.. |
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Definition
| position head, assess snoring, breathing sounds, oxygen, suction PRN |
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Term
| in PACU head of bed should be.. |
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Definition
| 15-30 degrees unless contraindicated |
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Term
| other PACU care/assessments |
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Definition
| incisional site, check tubes and drainage amount, coughing/deep breathing, level of consciousness/neuro, IV solution and patency |
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Term
| for PACU care, nurse should assess.. |
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Definition
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Term
| post surgical nursing diagnoses... |
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Definition
| activity intolerance, impaired skin integrity, ineffective thermoregulation, risk for imbalanced nutrition- constipation, urinary retention, injury. anxiety |
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Term
| prblems assoc. with post op.. |
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Definition
| pulmonary infection/hypoxia, DVT, hematoma/hemorrhage, PE, wound dehiscence or evisceration |
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Term
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Definition
| Pain is whatever a person says it is, existing whenever the experiencing person says it does” |
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Term
| JCAHO says that pain is.. |
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Definition
| “pain is assessed in all patients” and that “patients have the right to appropriate assessment and management of pain. |
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Term
| provocative and palliative |
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Definition
| what makes it worse or better? |
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Term
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Definition
1 — awake and alert; no action necessary
2 — occasionally drowsy, but easy to arouse; no action necessary
3 — frequently drowsy, drifts off to sleep during conversation; reduce dosage
4 — somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone |
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Term
| post op epidural analgesia is used with |
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Definition
| used with thoracic, orthopedic, OB, & major abdominal surgery |
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Term
| post op epidural analgesia produces.. |
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Definition
| more pronounced anesthesia, respiratory depression |
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Term
| potential post op complication- fig 20-4 p 533 brunner |
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Definition
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Term
| impaired wound healing can be caused by.. |
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Definition
| poor technique, chronic illness, nutritional impairments |
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Term
| impaired wound healing symptoms/signs |
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Definition
| erythema, tenderness, warmth, exudate |
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Term
| Impaired wound healing prevention.. |
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Definition
| hand washing, clean or sterile technique, pt education, review notes on wound care |
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Term
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Definition
| separation/opening of an incision |
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Term
| dehiscence can be caused by.. |
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Definition
| obesity, malnutrition, impaired circulation, strain on incision |
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Term
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Definition
| increased drainage, visible layers of skin |
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Term
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Definition
| splint incision, educate patient |
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Term
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Definition
| organs/tissue protrude through incision |
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Term
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Definition
| sudden sense of splitting. sudden drainage |
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Term
| treatment of evisceration |
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Definition
| stay calm and with patient!!!!, sterile dressing saturdated with normal saline, notify physician asap!, monitor VS, prepare for surgery |
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Term
| signs of postop hypoxemia |
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Definition
| pao2 less than 60, o2 90-92%, agitation, hyper/hypotension, tachy/bradycardia |
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Term
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Definition
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Term
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Definition
| collapse of alveoli, dyspnea, cyanosis, tachydyspea, tachycardia, productive cough, adventitious breath sounds |
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Term
| prevention of atelectasis- |
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Definition
| deep breathing x10/hr, cough+/- splinting incision, turn q 1-2 hours |
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Term
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Definition
| history of PE, women on high estrogen, injury to venous system, fracture of long bones |
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Term
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Definition
| sudden chest pain, tachycadria, low BP, restlessness, decreased breath sounds, |
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Term
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Definition
| leg exercise, ambulation, prevention DVT |
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Term
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Definition
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Term
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Definition
| TCDB, spirometer, early ambulation |
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Term
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Definition
| interruption of suture line, bleeed! |
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Term
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Definition
| decreased BP, increased P, disorientation, cool/clammy skin, pallor, sanguienous drainage |
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Term
| treatment of hemorrhage, what does the nurse do? |
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Definition
| first, ASSESS VS, then notify surgeon. |
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Term
| what is a genitourinary/GU complication? |
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Definition
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Term
| what can cause urinary retention? |
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Definition
immobility, positioning, anesthesia, certain surgeries
treated by assessing i/o, bladder fullness and positioning |
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Term
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Definition
| tigan, phenegran, compazine |
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Term
| nausea/vomiting can be caused by.. |
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Definition
| anesthesia, medications, type of surgery |
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Term
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Definition
| walking, rocking chair, assessment of abdomen, no ice chips or straws |
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Term
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Definition
| lack of peristalsis, lack of bowel sounds, caused by abdominal surgery |
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Term
| treatment for paralytic ileus.. |
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Definition
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Term
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Definition
| lack of fiber, decreased gastric motility, opioids, treated by fiber/fluids and activity |
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Term
| bowel obstruction can be caused by |
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Definition
| edema, scar tissue impacted stool |
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Term
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Definition
| high pitched tinkling bowel sounds, diarrhea, treatment of obstruction- NG tube |
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Term
| psychosocial complications.. |
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Definition
| anxiety, fear, grief, sensory deprivation overload |
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Term
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Definition
| meds, appts, symptoms of infection, care of tubes/incisions, activity and diet restrictions |
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Term
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Definition
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Term
| blood vessels in skin dilate to dissipate heat, T/F? |
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Definition
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Term
| resistance to injury is affected by.. |
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Definition
| age, amount of underlying tissue and illness |
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Term
| adequately nourished and hydrated body cells are.. |
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Definition
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Term
| infant's skin/mucous membranes.. |
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Definition
| are easily injured and subject to infection |
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Term
| the structure of skin changes as.. |
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Definition
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Term
| whos most susceptible to skin injury? |
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Definition
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Term
| persistent moisture on skin can cause |
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Definition
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Term
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Definition
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Term
| Which one of the following types of wounds is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact? |
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Definition
| contusion- caused by a blunt instrument and result in bruising or hematoma |
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Term
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Definition
| is the rubbing or scraping of epidermal layers of skin |
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Term
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Definition
| is the tearing of skin and tissue with a blunt or irregular instrument |
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Term
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Definition
| is the tearing of a structure from normal anatomic position |
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Term
| The NUMBER ONE determinant of wound healing is |
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Definition
| tissue perfusion/ blood flow |
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Term
| phases of wound healing.. |
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Definition
| hemostasis, inflammatory response, proliferation, maturation. |
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Term
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Definition
| involved blood vessels constrict and clotting begins, occurs immediately after injury, causes swelling and pain, platelets signal to other cells to come help |
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Term
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Definition
| WBC's move to the wound, lasts about 4-6 days, macrophages enter wound area, and remain for extended period, ingest debris and release growth factors that attract fibroblasts- generalized body response |
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Term
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Definition
| granulation tissue is formed to fil the wound, 2-3 days after injury and take 2-3 weeks, new tissue is built, capillaries grow across wound, granulation tissue forms a foundation for scar tissue development |
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Term
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Definition
| collagen is remodeled, forming a scar, final stage of healing collagen is remodeled, scar becomes a flat thin white line |
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Term
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Definition
| infection, hemorrhage, dehiscence and evsiceration, fistula formation |
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Term
| Which one of the following wound complications is caused by overhydration related to urinary and fecal incontinence? |
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Definition
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Term
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Definition
| Maceration is caused by overhydration related to incontinence that causes impaired skin integrity |
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Term
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Definition
| Necrosis is dead tissue present in the wound that delays healing. |
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Term
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Definition
| Edema is swelling at a wound site that interferes with blood supply to the area. |
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Term
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Definition
| Desiccation is the process in which the cells dehydrate and die. |
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Term
| stages of pressure ulcers.. |
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Definition
Stage I—nonblanchable erythema of intact skin
Stage II—partial-thickness skin loss
Stage III—full-thickness skin loss; not involving underlying fascia
Stage IV—full-thickness skin loss with extensive destruction
Unstageable—base of ulcer covered by slough and or eschar in wound bed |
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Term
| A Stage III pressure ulcer requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. T/F |
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Definition
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Term
| what should you use to clean a pressure ulcer? |
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Definition
| .9% normal saline to irrigate and clean ulcer |
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Term
| wound assessment criteria |
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Definition
| inspect sight and smell, palpate for appearance, drainage, and pain, CHECK sutures/drains or tubes/manifestation of complications |
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Term
| presence of infection symptoms |
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Definition
| wound is swollen, deep red color, feels hot, drainage is increased and possibly purulent. foul odor may be noted, wound edges |
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Term
| wound drainage assessment |
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Definition
| serous, sanguineous, seprsamgiomepis, purulent |
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Term
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Definition
| color, odor, consistency, amount |
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Term
| purposes of wound dressings.. |
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Definition
| provide comfort, remove necrotic tissue, infection control, absorb drainage, maintain a MOIST WOUND environment, protect wound from further injury, protect skin surrounding the wound |
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Term
| types of wound dressings.. |
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Definition
| telfa, gauze dressings, transparent dressings |
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Term
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Definition
| roller bandages, circular/spiral turn, figure eight turn, recurrent stump bandage |
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Term
| straight binders are used for.. |
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Definition
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Term
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Definition
| rectum, perineum, and groin area |
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Term
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Definition
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Term
| purposes of wound dressings.. |
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Definition
| provide comfort, remove necrotic tissue, infection control, absorb drainage, maintain a MOIST WOUND environment, protect wound from further injury, protect skin surrounding the wound |
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Term
| types of wound dressings.. |
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Definition
| telfa, gauze dressings, transparent dressings |
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Term
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Definition
| roller bandages, circular/spiral turn, figure eight turn, recurrent stump bandage |
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Term
| straight binders are used for.. |
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Definition
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Term
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Definition
| rectum, perineum, and groin area |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| jackson-pratt drain, hemovac drain |
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Term
| penrose drain looks like.. |
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Definition
| tube with gauze around it wit safety pin through it |
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Term
| jackson pratt drain looks like.. |
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Definition
| tube with grenade pump thingy on end |
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Term
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Definition
| red-protect, 0 nonviable tissue |
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Term
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Definition
| yellow-cleanse, <50% nonviable tissue |
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Term
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Definition
| Black- debride- >50% nonviable tissue |
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Term
| mixed wound classification |
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Definition
| containts components of RY and B wound |
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Term
| color classification for wounds.. |
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Definition
| DO NOT RELATE TO ACTUAL COLOR OF WOUND |
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Term
| effects of applying heat.. |
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Definition
| dialtes peripheral blood vessels, increases tissue metabolism, reduce blood viscosity and increases capillary permeability, reduces muscle tension, helps relieve pain |
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Term
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Definition
| constructs peripheral blood vessels, reduces muscle spasms, promotes comfort |
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Term
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Definition
| hot water bag/bottles, electric pads, aquathermia pads, hot packs, moist heat, sitz bath, warm soaks |
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Term
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Definition
| ice bags, cold packs, hypothermia blankets, moist cold |
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Term
| what environment is best for wound healing? |
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Definition
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Term
| transparent film bandages are good for.. |
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Definition
| wound w minimal drainage, stage 1 PU, wounds that are small, secure catheters/IVs, |
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Term
| high colloid dressings are good for.. |
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Definition
| partial and full thickness wounds, light to moderate drainage, wounds w necrosis or slough, not for use with infected wounds |
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Term
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Definition
| partial/full thickness wounds, burns, necrotic wounds, dry wounds, minimal exudate, and infected wounds. |
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Term
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Definition
| moderate/heavy exudate, tunneling wounds, moist red and yellow wounds, not for use with small wounds |
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Term
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Definition
| absorb lots of drainage, use around tubes and drains, not for use with wounds with dry eschar |
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Term
| antimicrobial dressings are good for.. |
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Definition
| draining/exudate/non healing wounds to protect from contamination/infection. acute/chronic wounds |
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Term
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Definition
| partial or full thickness wounds, infected/non infected, skin grafts, tunneling wounds, wounds with exudate |
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Term
| 5 aspects of braden scale |
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Definition
| sensory perception, moisture, activity, mobility, nutrition, friction/shear |
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Term
| a "1" on a braden scale is.. |
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Definition
| bad, higher numbers are better. |
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Term
| risk level on braden scale.. |
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Definition
| <9- bad!, 10-12- still bad, 13-14- moderately bad, 15-18- not that bad, 19-23- no risk |
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Term
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Definition
| two or more tissue layers slide on each other, stretching sub q blood vessels, obstructing blood flow and contributing to pressure ulcers. |
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Term
| nutritional factors that effect wound healing |
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Definition
| protein, vitamin C, and fluid deficiencies decreases skin elasticity and increases chance of skin breakdown |
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Term
| how do you measure postvoid residual?? |
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Definition
| bladder scanner- urine left in bladder after elimiation, or use intermittent catheterization. |
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Term
| a post void residual of ?? is deemed necessary for catheterization |
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Definition
| a PVR of greater than 150 ml |
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Term
| a PVR of over 150 ml can increase pt's risk of.. |
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Definition
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Term
| MAIN difference between gen. and regional anesthesia? |
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Definition
| general- asleep, temporary paralysis, reg- no sleep, relfex loss and analegesia. |
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Term
| older people and pain meds.. |
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Definition
| you may undermedicate, or overmedicate them accidentally. |
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Term
| when patient is taught about postop "coughing" make sure to tell them... |
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Definition
| how to splint their incision while doing it with a bath blanket or pillow |
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Term
| effective post op coughing.. |
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Definition
| semi-fowlers, splint incision with pillow, deep inhale/exhale via nose 3 times, take a deep breath-hold for 3 seconds,"hack out" for 3 short breaths.. w mouth open, inhale and cough deeply once or twice, take another deep breath |
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Term
| how often should patient practice breathing/coughing? |
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Definition
| every 1-2 hours while awake |
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Term
| patient in postop should be positioned.. |
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Definition
| on their side, unless contraindicated, decerases risk for aspiration |
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Term
| pts at risk for impaired wound healing.. |
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Definition
| immobile, elderly, obese, malnourished, babies. |
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Term
| nonpharmacologic pain mgmt.. |
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Definition
| massage, position change, relaxation, guided imagery, meditation, music |
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