Chpt 2. PLAN OF CARE Flashcards
The purpose of a plan of care is to_______
The purpose of a plan of care is to identify nursing interventions that will help the patient meet
desired outcomes.
. Ensuring ____ ____ ____ is the goal for any plan of care, regardless of
patient age, operative setting, or procedure being performed.
. Ensuring safe patient care is the goal for any plan of care, regardless of
patient age, operative setting, or procedure being performed.
TRUE OR FALSE?
To be able to evaluate
whether a desired patient goal has been met, the outcome must be specific and written in measurable
terms.
TRUE
The three patient-centered quadrants—safety, physiological responses to surgery, and
patient and family behavioral responses—serve as the__________
The three patient-centered quadrants—safety, physiological responses to surgery, and
patient and family behavioral responses—serve as the framework for the development of a plan of care.
TRUE OR FALSE
The temperature of the room, IV fluids and prep
solutions, and exposure of the surgical site don’t all
contribute to heat loss.
FALSE!
The temperature of the room, IV fluids and prep
solutions, and exposure of the surgical site all
contribute to heat loss.
________ increases the risk for a surgical
site infection (SSI),
- causes discomfort,
-increases the risk for pressure ulcer development,
and
-adversely affects the coagulation cascade,
resulting in an increased risk for bleeding
and
-delayed wound healing, which alters tissue
perfusion and prolongs recovery time.
Hypothermia increases the risk for a surgical
site infection (SSI), causes discomfort, increases
the risk for pressure ulcer development, and
adversely affects the coagulation cascade,
resulting in an increased risk for bleeding and
delayed wound healing, which alters tissue
perfusion and prolongs recovery time.1
________because of their increased body surface-to-weight
ratio and thinner layer of subcutaneous fat, have
difficulty maintaining a normal body temperature
Infants,
because of their increased body surface-to-weight
ratio and thinner layer of subcutaneous fat, have
difficulty maintaining a normal body temperature
TRUE OR FALSE!
Infants are more at risk for hypothermia than the elderly.
FALSE!
In terms of temperature regulation, size does
matter. The very young and the frail elderly are
both at risk for hypothermia.
Simple physiological responses to hypothermia (ie,
shivering, vasoconstriction) may tax an already compromised cardiovascular system in the elderly
The perioperative plan of care (FOR THIS)
includes interventions such as using supplemental oxygen, maintaining normothermia, and ensuring
adequate volume replacement to support blood flow and oxygenation to potentially compromised tissue.
Altered Tissue Perfusion
Acute and chronic cardiovascular and respiratory conditions put the elderly at increased risk for altered tissue perfusion. One intervention that the RN circulator can employ is to____ bony prominences to ____ pressure and encourage adequate tissue perfusion
Acute and chronic cardiovascular and respiratory conditions put
the elderly at increased risk for altered tissue perfusion. One intervention that the RN circulator can
employ is to PAD bony prominences to DECREASE pressure and encourage adequate tissue perfusion
TRUE OR FALSE!
Patients with any condition that alters tissue perfusion (ie, vascular disease, diabetes
mellitus, immobility, obesity) are at increased risk for impaired skin integrity.
TRUE
Tissue that is not oxygenated is at increased
risk for_____ and _____healing.
Tissue that is not oxygenated is at increased
risk for INFECTION and DELAYED healing.
Can anxiety and stress influence the outcomes of the surgical procedure?
yes
THIS EMOTIONAL RESPONSE CAN:
• triggers the fight-or-flight response (eg, increased heart rate, respiratory rate, and blood pressure);
• interferes with problem solving, which can affect judgment, concentration, and the ability to
make sound decisions; and
• decreases the immune response
ANXIETY
WHAT ARE SOME NON-PHARMACOLOGICAL WAYS TO HELP DECREASE ANXIETY AND STRESS?
Nonpharmacological techniques include clear communication and distraction techniques (ie, humor, music), which are especially useful during the preoperative
period and during procedures performed under local anesthesia. Humor in a culturally appropriate way
has been found to decrease stress, increase pain tolerance, and increase mood.1
