Careplans

Question 0

Name some care plans

Answer 0

Peripheral venous cannulation(PVC) chart
NEWS/GCS
Cannard Falls Risk- Must be completed within 24hrs of admission to each ward.
Waterlow Pressure risk assessment- should be completed within 24hrs
Wound management chart.
Fluid Balance Chart.
Nutrition Profile- MUST Chart- Must be completed within 24hrs of an admission to ward.
FAST- Alcohol assessment of misuse
Bristol Stool Chart- bowel movements
Medication administration record sheet(MARS)

Question 1

National Early Warning Score(NEWS)

Answer 1

An early way of determine a degree of illness.

It involves:
Heart rate(pulse)51-90bpm
*Normal range 60-100
*Tachycardia >100
*Bradycardia 20
Respiratory 12-20bpm
*Bradypnea- 12bpm
*Tachypnea- 20bpm
Saturation >96
Systolic BP 111-219
*Hypotension- 140/90
Temperature  36.0-38.0
Hypothermia- 38.5
Pain score 1-10
Nausea- 1-3
Urine output
AVPU - A

Question 2

Wound assessment observes what

Answer 2

Wound Dimesions: width, depth, length
Tissue type:
necrotic(black)
sloughy(yellow/green)
granulating(red)
Epithelialising(pink)
Hypergranulating(red)
Haematoma
Bone/tendon
Wound exudate levels: low, moderate, high
Peri-wound skin: 
Macerated- when skin is consistently wet and softens, turns white and gets easy infected
Oedematous- swollen skin due to water retention
Erythema- redness of the skin
Excoriated- is lesions or abrasions of the skin
Fragile
Signs of infection:
Heat, slough/necrosis, pain, exudate, odour, granulation
Treatment:
Debridement
Absorption
Hydration
Protection
Palliative

Question 3

What is APIE

Answer 3

Assessment- what is the situation
Plan- what is the plan of action
Implementation- action
Evaluate- what was the results of the action

Question 4

What is a SSKIN Bundle

Answer 4

Example:
Surface-special mattress, pressure foam cushions, repo- boots.
Skin Inspection- poor mobility, poor nutrition, dehydration,pain assessment, incontinence, wound- size, exudate, odour,
Keep Moving: encourage patient movement, patient education, bed positioning dependent on score, movement and handling
Incontinence: assess for products, prompting, assess for issues such as poor mobility, use barrier creams
Nutrition: red tray, fluid intake, oral hygiene, supplement drinks

Question 5

The steps to doing a written care plan(APIE)

Answer 5

Assessment: collect data from medical records, physical assessment(signs, symptoms), assess patients ADL’s, head to toe examination.
Planning: interventions, goals i.e stabilise hyperglycaemia, discharge with suitable equipment etc
Implementation: care plan in to action.
Evaluation: review outcomes been met, results etc