NFDN 2003 MIDTERM STUDY GUIDE WITH COMPLETE SOLUTIONS

NFDN 2003 MIDTERM STUDY GUIDE WITH COMPLETE SOLUTIONS Components of SBAR - Correct Answer ️️ -A framework and a clinical pathway Situation Background Assessment Recommendation clinical pathways (care mapping) - Correct Answer ️️ --tools used in case management of client care -mapped out day by day for admission to discharge Purpose of clinical pathways - Correct Answer ️️ --critical to meet expected outcomes -standardized care Elements of clinical pathways - Correct Answer ️️ --Client population -time frames -interventional categories -meet expected outcomes -variance record Concept Mapping - Correct Answer ️️ -used for: -abdominal absences -nutrition/ fluid imbalance -pain -anxiety -infection Mentorship benefits - Correct Answer ️️ --support of new grade -foster growth of future generations -creates long term connections -role models Mentorship Pitfalls - Correct Answer ️️ --Personality conflict -imposing their style on you -social issues time managment skills - Correct Answer ️️ --anticipate events -ensure patient safety -must do vs should do -prioritize Risk factors affecting skin integrity - Correct Answer ️️ --Lifestyle -Developmental -Physiological -Environmental Red wound - Correct Answer ️️ --healing wounds, granulation tissue -inflammatory, proliferate, or maturation phase of healing -need t be kept clean and moist yellow wound - Correct Answer ️️ --fibrous slough or exudate -infected and not ready to heal -require removal of slough black wound - Correct Answer ️️ --Presence of eschar (necrotic tissue) -not ready to heal -Must have eschar removed for healing to take place Combination color - Correct Answer ️️ --use most severe treatment serous drainage - Correct Answer ️️ -clear, watery plasma sanguineous drainage - Correct Answer ️️ -Bright red serosanguineous drainage - Correct Answer ️️ -Mixture of plasma and red blood cells, pale red and watery purulent drainage - Correct Answer ️️ --necrotic tissue -pus -thick yellow -green -tan -brown factors impairing wound healing - Correct Answer ️️ --infection -malnutrition -age -obesity -impaired oxygenation -smoking -drugs -vascular disease -radiation -wound stress Factors promoting wound healing - Correct Answer ️️ --provide adequate nutrition -cleansing of the wound -maintain moist wound bed -dress wound -drain the wound -drain care to promote healing -removing sutures s and staples Common diagnostic tests to assess altered protective mechanisms - Correct Answer ️️ --CBC (WBC, neutrophils) -Pre-albumin: poor nutrition for short time and Albumin levels: poor nutrition for long period -Glucose levels -Radiology studies Pharmacological treatment of wounds - Correct Answer ️️ -Will be identified in the doctors orders Non pharmacological treatment of wounds - Correct Answer ️️ --Apply heat or cold compress (indicated in dr orders) -Assess pain Complications of altered protective mechanisms - Correct Answer ️️ --inflammation (edema, heat and pain) -infection (watch for fever, wound drainage, and swelling) -hemorrhage (watch for distention, swelling, and obvious bleeding) -fistula (abnormal passage between two organs) -dehiscence (separation of wound edges) -evisceration (internal organ protrusion) Wound Assessment - Correct Answer ️️ --use cm -assess for tunnelling -measure over the wound, do not touch -date, time, and patients position