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NFDN 2003 Midterm Review test exam with verified solutions
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NFDN 2003 Midterm Review test exam with verified solutions
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NFDN 2003 Midterm Review testexam with verified solutions
What does SBAR stand for? - answer Situation
Background
Assessment
Recommendation
Concept Map - answer -another method of recording a nursing care plan
-the nursing process is recorded in a visual diagram of patient problems
and interventions that illustrates the relationships among clinical data
Clinical (critical) pathways - answer -directs the entire health care team
in the daily care goals for select health care problems
-includes: nursing care plan, specific interventions, and a documentation
tool
-it describes the patient care required at specific times in the treatment
-multidisciplinary approach
Purpose of clinical pathway - answer Critical to meet expected outcomes
Standardize care
Reduce delays in care
Reduce costs
What is the purpose of SBAR? - answer -All events are critical to meet
outcomes
-Standardization of Care
-Can be individualized
-Reduces duplication and delays in care
-Reduces cost of care
,What does SBAR do? - answer -Communication Framework
-Clear & Direct communication with Care Providers
-Clinical Pathways
-Care maps
-Effective & Efficient Processes
-Care mapped from entry to exit
What is the purpose of dressing? pg. 1318 - answer -Like a second skin to
something that has been broken
-to control bleeding, to prevent infection, to absorb blood
-aids in homeostasis
-provides a moist environment
What type of wounds need dressing? - answer wounds with extensive
tissue loss
What is gauze? - answer -Absorbent and WICK away any drainage.
-Does not irritate the wound.
Why would we use gauze? - answer It gathers lots of secretions, for
something that is draining lots
Telfa - answer -Non-adherent gauze
-Telfa can be used over clean wounds with little or no drainage.
-Does not stick and drainage can pass through to the gauze.
When would we use occlusive dressing? - answer -Anytime we do not
want something to go in/out of the wound because it is impermeable to
external bacteria and other contaminants
-eg. chest tube
, Occlusive (Hydrocolloid) - answer -Adhesive and occlusive.
-Interacts with wound fluid to provide a moist environment
-Surface touching the wound forms a gel and maintains a moist
environment.
-Can be used on clean, granulating wounds as well as for wounds that
need debriding.
-They slowly liquify necrotic tissue.
-Can be left in place until seal is broken, allowing for enhanced healing.
-Use on ulcer type wounds.
-WATCH CAREFULLY AS SOME HYDROCOLLOIDS CAN LEAVE RESIDUE IN
WOUND THAT LOOKS LIKE PUS
-minimal absorption, maintains wound med moisture
-impermeable to external bacteria and other contaminants
-must be left in place for 5-7 days
-should NOT be used in heavily draining, or full thickness infected wounds
What assessment do you do pre/post dressing change? - answer -When
you go in, what do you see? Is there drainage on the top, moist, what type
of drainage and how much?
-If the were medicated, and how they tolerated the procedure
Complex wound irrigation - answer -we irrigate from CLEAN to DIRTY
-use a single squeeze 100mL saline bottle this delivers saline at the
proper pressure to avoid trauma to the wound bed
-used to flush the area with a constant low-pressure flow
-cleans wounds of exudate and debris
-do not leave irrigant pooled in wound bed, allow gravity to assist in
drainage
complex wound packing - answer -first you must assess size, depth,
shape, tunnelling, and undermining
-wound should not be packed too tightly, use a light touch
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