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Fundamentals I (NR224) Exam 2 Notes

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Chamberlain College of Nursing

Fundamentals I (NR224)

Funds exam 2 notes

Funds Exam 2
 Patient is at risk for skin breakdown:
o Provide diet high in protein, bc inadequate intake of protein, iron, calories, &
vitamins increases the risk for skin breakdown
 If looking at lab values for patient  high WBC count= risk for infection drainage,
increased temperature
 Serum albumin level is a good indicator of nutritional status of client
o Less than 3.5= poor nutrition, delay in healing process, may lead to infection
 Drainage on dressings:
o Serous yellowish color just
o Purulent thick & odorous
o Senguenous bloody
o Sero-senguenous watery/ red
 Obtain a wound culture on a patient, PRIOR to obtaining the culture, remove all wound
exudate & any residual antimicrobial cream
o Clean w/ normal saline, irrigate prior to obtaining the specimen
 Recognize that hematuria (blood tinged urine) is a manifestation of bladder infection or
kidney stones
 Cloudy or concentrated urine, could be RBC/WBC/bacteria
o Foul smelling urine: could be UTI
 Culture & sensitivity from someone with foley/indwelling cath
o From the port, cleanse port (for culture & sensitivity), withdraw 3-5ml (for c&s),
of urine to get an adequate amount for the urine, 30ml (for urinalysis)
 Teach female patient wipe FRONT TO BACK  perineum to anus
 Older adult patients are usually confused, confusion is a clinical finding of UTI’s in older
patient
 Sudden onset of urinary incontinence or increased confusion can indicate the presence
of UTI or bacterial cystitis in older patient

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Fundamentals I (NR224) Exam 2 Notes

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