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
Which age group is more likely to undergo emergence delirium?
Adolescents are more likely to undergo emergence delirium than
children or adults.
TRUE OR FALSE?
Old people may lose the ability to react physiologically to stress/anxiety.
The geriatric population’s normal aging processes, along with the presence of comorbidities, may inhibit the ability to react to signs and symptoms of stress (ie, elevated heart rate and blood pressure)
TRUE OF FALSE?
Surgical site infections are the second most common and second most costly health care–acquired
infections.
FALSE!
Surgical site infections are the most common and most costly health care–acquired
infections.
Patients under droplet or airborne precautions must wear a_____ during
transport
Patients under droplet or airborne precautions must wear a mask during
transport
what kind of precautions? (airborn, contact, etc)
_______precautions
are used for pathogens that are spread through
either direct or indirect patient contact. Direct
transmission follows the passage of infectious
organisms between two people; indirect transmission
occurs after contact with contaminated
surfaces (eg, OR bed, instruments, equipment).
Single-use patient care items and thorough
cleaning and disinfecting of nondisposable equipment
will decrease the risk of indirect transmission
of pathogens.
Contact precautions
are used for pathogens that are spread through
either direct or indirect patient contact. Direct
transmission follows the passage of infectious
organisms between two people; indirect transmission
occurs after contact with contaminated
surfaces (eg, OR bed, instruments, equipment).
Single-use patient care items and thorough
cleaning and disinfecting of nondisposable equipment
will decrease the risk of indirect transmission
of pathogens.18
What kind of precautions? (airborn, contact..etc)
___ precautions are instituted for pathogens that are small (ie, 5 micrometers or less) and therefore can stay
suspended in the air. These pathogens are easily
spread through sneezing, coughing, or talking.
Place patients suspected of or diagnosed with an
airborne disease in a negative-pressure room to
prevent air circulation of the pathogen to other
areas of the hospital.
Airborne precautions
are instituted for pathogens that are small
(ie, 5 micrometers or less) and therefore can stay
suspended in the air. These pathogens are easily
spread through sneezing, coughing, or talking.
Place patients suspected of or diagnosed with an
airborne disease in a negative-pressure room to
prevent air circulation of the pathogen to other
areas of the hospital.1
When should you wash your hands? list 6 times
• Before and after every patient contact
• After known or potential contact with the
patient’s bodily secretions or excretions
• Before and after eating
• After using a restroom
• Before donning gloves and after removing
gloves or other PPE
• Anytime hands are visibly dirty or
contaminated
After a person with an airborned disease has been care for in the OR, can we re-use that room after turn-over? why or why not?
After a person with an airborne disease has
been cared for in the OR, the OR should
be closed and not cleaned until 99% of the
airborne particles have been removed from the
air (eg, 15 air exchanges/hour for 28 minutes).
Pathogens greater than 5 micrometers in size require ______precautions label.
Although also spread through sneezing, coughing, and talking, these larger microbes tend to settle to
the ground within three feet of the patient source. Distance from the source, therefore, can be considered
an additional PPE as a means of infection control.
Pathogens greater than 5 micrometers in size require DROPLET precautions.
Although also spread through sneezing, coughing, and talking, these larger microbes tend to settle to
the ground within three feet of the patient source. Distance from the source, therefore, can be considered
an additional PPE as a means of infection control.
AIRBORNE, CONTACT, OR DROPLET, AND TYPE OF PPE
- HIV
- Hepatitis B
- Hepatitis C
- Staphylococcus aureus
- Clostridium difficile
CONTACT
• Gown and gloves
• Mask, and eye protection if there is risk of
contact with eyes or mucous membranes
AIRBORNE, CONTACT, OR DROPLET, AND TYPE OF PPE
- Meningitis
- Pneumonia
- Mumps
- Rubella
- Pertussis
Droplet
• Surgical mask
• Gloves, gown, and eye protection if there is
risk of spray to eyes or mucous membranes
AIRBORNE, CONTACT, OR DROPLET, AND TYPE OF PPE
- Mycobacterium tuberculosis
- Varicella
- Rubeola
Airborne
• NIOSH N-95 fit-tested respirator
• Gloves, gown, and eye protection if there is
risk of spray to eyes or mucous membranes
TRUE OR FALSE?
Untreated or undertreated pain prolongs recovery, increases the risk for developing chronic pain, and is a
huge patient dissatisfier
TRUE
EFFECT OF THESE HERBS? PLAN OF CARE?
- Feverfew
- Garlic
- Ginger
- Gingko Biloba
- Ginseng
- Vitamin E
INCREASE BLEEDING TIME
• Have hemostatic supplies on hand
EFFECTS OF THE HERBS? PLAN OF CARE?
- Echinacea
- Kava
MAY CAUSE LIVER INFLAMMATION
• Anticipate increased bleeding
• Have hemostatic supplies on hand
• Anticipate delayed induction and/or
prolonged emergence
EFFECTS OF THESE HERBS? PLAN OF CARE?
- Goldenseal
- Licorice
May elevate blood pressure
- Anticipate increased bleeding
- Have hemostatic supplies on hand
EFFECTS OF THESE HERBS? PLAN OF CARE?
- Kava
- St John’s Wort
- Valerian
MAY PROLONG THE EFFECTS OF ANESTHESIA
• Anticipate delayed emergence
How do you measure infants & young childrens’ pain?
For infants
and young children, use pain intensity and pain
distress scales (eg, FACES, FLACC [Face, Legs,
Activity, Cry, Consolability]) rather than the standard
zero-to-10 numeric pain intensity scale.
