Final Exam

Question 1

Describe the common features of each: primary intention, secondary intention, and third intention.

Answer 1

Primary intention (primary union) - A clean, approximated incision that is closed with a suture or other appropriate product. No discharge from wound or tissue loss. Nominal scar formation.

Secondary intention - The wound heals by granulation, leading to wound contracture. Repeated debridement may be necessary. Infection and tissue loss are present. Scar formation and contracture may result in scar revisions.

Third intention (delayed primary closure) - Delayed wound closure due to considerable tissue loss and/or gross infection. Wound is not devascularized. Deep sutures are not used to avoid granuloma formation. Wound is cleaned, debrided, and packed. Eventual approximation of clean granulation surfaces is achieved.

Question 2

How can the patient’s health influence wound closure and healing?

Answer 2

A patient’s health can influence wound closure and healing based on their nutrition and the presence of co-morbidities. If a patient has diabetes and experiences malnutrition, it negatively impacts wound healing due to the effects of the processes on the body, which creates a poor state for the body to adjust. This makes the body more susceptible to SSIs.

Question 3

Does your facility provide NPWT devices? Where are the devices stored? Are all of the supplies needed for the application of this dressing stored together? If not, where else would you need to go in order to have everything for the surgeon? How do you enter the patient charge for the use of this device? Is there additional paperwork that must follow the patient to the subsequent nursing units?

Answer 3

Yes, the facility does provide NPWT devices.

They are stored within the normal storage room.

All of the supplies needed are stored together.

Question 4

Wound Designation Chart

Answer 4

Intentional
-Surgical: an incision made into intact tissue

Unintentional
-Traumatic: can be life-threatening or non-life threatenting injuries

-Incidental: pressure-related injury that is caused by compromised circulation from inadequate, inappropriate surgical positioning

-Chronic: chronic pressure injury, can be caused by tissue loss from either arterial insufficiency or venous

Question 5

Suture Material Classifications

Answer 5

Natural or synthetic material

Absorbable or non-absorbable suture strand

Monofilament or multifilament

Question 6

Suture Material Characteristics

Answer 6

Physical configuration
-Mono or multifilament
-Coating
-Capilarity: capability of fluid that is absorbed by suture to be transferred along length of suture
-Diameter: suture size defcreases as the zeros expressing the size increase (3-0 is smaller than 2-0)
-Tensile strength: measurement of the suture strand’s ability to resist breakage
-Knot strength: force required to allow a knot to slip on itself
-Elasticity: measurement of the suture’s ability to recover its primary form and length after stretching or other deformation
-Plasticity: measure of the suture’s capability to be stretched, tied, or misshapen without breaking and maintaining the new form
-Memory: inherent capability of suture to keep/return its original shape
-Knot tensile strength: breaking point of a knotted suture

Handling: suture’s bending ability and how easily a suture can move through tissue and be tied down
-Pliability: how easy suture bends
-Tissue drag: how easy suture slips through tissue (lower drag = more easy)
-Knot tying: how easy suture can be tied (more friction = more difficult)
-Knot slippage: ability of knots to be slid down suture (bad ability = no wound approximation)

Tissue Reaction
-Inflammation
-Absorption
-Infection potential
-Allergic reaction

Question 7

Stich Types

Answer 7

Interrupted: single sutures that are tied independently

Continuous/running stitch: uninterruped suture line

Retention suture: a heavy suture that reinforces the primary suture line

Subcuticular stich: a suture line under the epidermis

Purse-string: a suture placed around a circular wound

Question 8

Skin Closure Options

Answer 8

Staples
-Advantages: easy to use, proiders uniform incisional tension, faster wound closure
-Disadvantages: requires extraction unless staples are absorbable

Adhesives
-Advantages: reduced risk of infection, less scarring, eliminates skin closure device removal
-Disadvantages: limited to use for superficial wounds, higher allergic reaction rate, not optimal for slow-healing conditions

Adhesive strips
-Advantage: less expensive than other closure methods
-Disadvantage: can loosen with moisture, causing wound compromies

Zippers
-Advantage: skin stretching forces are distributed over a wide surface area; away from the wound edges, may replace the need for a tissue expander, faster application than suture, may provide a more cosmetic outcome
-Disadvantage: cost, may not be an optimal option in the obese population

Question 9

SSI Categories

Answer 9

Superficial incisional
-Epidermis, dermis, subcutaneus layers
-Within 30 days after surgery

Deep incisional
-Fascial, muscle layers
-Beyween 30 and 90 days after surgery

Organ/space
-Organ/space
-Between 30 and 90 days after surgery

Question 10

Negative Pressure

Answer 10

Wound therapy used for difficult wounds that ahve not esponseded to other care methods

A specialized device applies constant, controlled, negative pressure to a wound into which a drianage spone has been placed

Mechanical tension on tissue
-Reduces edema
-Decreases bacterial load

Macro deformation
-Wound contracture

Micro deformation
-Microscopic interaction between the wound tissue and the dressing

Question 11

Drains

Answer 11

Used to provide an exit for blood, serum, bile, air, intestinal secretions, and pus

Create a portal of entry for pathogenic microorganisms

Aseptic technique is necessary when emptying closed systems and changing a wound drain dressing

Simple
-Penrose drain

Closed suction
-Hemovac
-Jackson-pratt
-Chest tube

Question 12

What are the goals of hemostasis?

There are 7

Answer 12

Decresae and control bleeding

Minimize the need for blood replacement

Optimize the surgical field view

Avoid major organ damage

Shorten the length of surgery and length of facility stay

Decrease the risk of infection

Decrease health care costs for patietns and facilities

Question 13

Risks of Impaired Hemostasis

Answer 13

Impaired visualization of the surgical field

Increased surgical time

Necessity of blood transfusion
Risks
-SSI
-Systemic inflammatory response syndrome
-Transfusion related acute lung injury
-Multiple organ failure
-Increased mortality

Question 14

What promotes a Culture of Safety?

Answer 14

The healthcare organization’s commitment to patient safety above all goals

A commitment to safety at all levels of the organization

A focus on systems, process improvement, and individual accountability

Sufficient resources

The ability of providers to discuss near-miss events and errors without reprisal

Question 15

Patient Safety Movement

Answer 15

As a result of landmark reports, there has been a shift from a culture of placing blame on an individual when errors occur to creating safer health care systems and standardizing processes (e.g. use of checklists, communication tools)

Question 16

Patient Safety Efforts

Answer 16

The parts of Universal Protocol in order for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery consists of three key steps:
-Conducting a pre-procedure verification process
-Making the procedure site
-Performing a time out

Question 17

What is a skill-based behavior error?

Answer 17

The provider has the knowledge for the action but there is little or no attention, or attention is diverted

Question 18

What is a knowledge-based performance error?

Answer 18

Errors in perception, judgment, inference, or interpretation

Question 19

What is a situational factor error?

Answer 19

Lack of attention and situational factors play a significant role in this type of error

Question 20

What processes demonstrate that a healthcare organization is committed to a culture of patient safety?

Answer 20

Accountability, creating a learning environment, and forming reliable teams for patient action

Question 21

What is an example of a situational factor error?

Answer 21

The RN is distracted by music, conversation, equipment noise, or alarms going off

Question 22

What is an example of a skill-based behavior error?

Answer 22

The nurse forgets to retrieve a unit of blood when called to conduct a sponge count

Question 23

What is an example of knowledge-based performance error?

Answer 23

The RN assumes an adult medication dosage applies, but the patient is a child

Question 24

What are the components of perioperative patient safety?

Answer 24

A safe environment

Appropriate staffing levels

Correct instrument care and cleaning

Fire safety

Infection prevention

Patient-centeredness

Prevention of patient falls

Prevention of sharps injury

Safe patient handling and movement

Sharps safety

Teamwork

Question 24

What are the components of perioperative patient safety?

Answer 24

A safe environment Appropriate staffing levels Correct instrument care and cleaning Fire safety Infection prevention Patient-centeredness Prevention of patient falls Prevention of sharps injury Safe patient handling and movement Sharps safety Teamwork

Question 25

What are the types of perioperative environment zones?

Answer 25

Unrestricted zone Semi-restricted zone Restricted zone

Question 26

What is an unrestricted zone?

Answer 26

Anyone is allowed in this zone Street clothes are permitted in this area Ex. public hallways and patient waiting areas

Question 27

What is a semi-restricted zone?

Answer 27

Secured from public access by signage, doors, and security measures (e.g. badge access) Wear clean surgical attire, a head cover, and facility-approved shoes Ex. hallways adjacent to operating room, sterile supply storge areas, and the sterile processing department

Question 28

What is a restricted zone?

Answer 28

Areas that are separated from semi-restricted doors where access is controlled with limited entrance Ex. operating rooms Clean surgical attire and PPE is required to be worn

Question 29

What is the basic team in the OR?

Answer 29

Surgeon, assistant, and scrub person at the sterile field RN circulator and anesthesia professional, who are not a part of the sterile field

Question 30

What are the axillary roles in the perioperative experience?

Answer 30

Allied health personnel PACU RNs and team members Perianesthesia RNs and team members Pharmacists, other physicians Radiology and laboratory team members Support personnel

Question 31

What is team communication?

Answer 31

Standardized preoperative verification and communication processes that should be followed to prevent wrong patient, wrong site, and wrong procedure events

Question 32

What is part of the preoperative verification process?

Answer 32

Include the patient in the verification process and use standardized safety checklists Patient identification -Always use at least 2 patient identifiers Surgical site marking -The surgeon or proceduralist marks the site of the surgery Time out - Pause in patient care immediately before the procedure begins to conduct a final assessment of the patient -Conduct a time out before the start of regional block, surgery, or other invasive procedure

Question 33

What are the components of the fire safety triangle?

Answer 33

An ignition source (ex. electrosurgical pencil) A fuel source (ex. surgical drapes) An oxidizer (ex. oxygen)

Question 34

When do you perform a fire risk assessment?

Answer 34

Before starting surgery

Question 35

What are life safety events in the OR?

Answer 35

Fire in the OR Malignant hyperthermia crisis Local anesthesia systemic toxicity (LAST) Cardiac arrest Latex allergy

Question 36

Who is at risk for MH complications, what are the S/S, and how is it treated?

Answer 36

Patient's who have a genetic history of reactions with anesthesia are more susceptible to MH. The gene for MH is autosomal dominant. S/S: increase in ETCO2, muscle rigidity, increase in temperature, and ultimately results in cardiac complications It is treated with an IV push of dantrolene sodium (mixed with sterile water). After dantrolene is administered, current s/s are treated, such as hyperkalemia.

Question 37

Who is at risk for LAST, what are the s/s, and how is it treated?

Answer 37

Patient's undergoing the use of blocks (i.e. bier block) are at risk for LAST. LAST occurs when a large amount of local anesthetic enters the systemic bloodstream, resulting in toxicity. S/S: periorbital numbness, change in hearing, and metallic taste Treatment is the use of 20% lipid emulsion and then treating any current displaying s/s. Late signs include seizures and cardiac activity.

Question 38

How can you prevent patient falls?

Answer 38

Assess patients for their risk for falls Implement fall prevention practices Document fall precautions

Question 39

What are 3 ways to prevent patient falls in the perioperative setting?

Answer 39

Don't leave the patient unattended in the OR until securely locked Use of safety strap Make sure both bed and stretcher are locked when transferring patient

Question 40

What are 3 ways to prevent a fire in the OR?

Answer 40

When bovie is not in use, make sure to put it in plastic holster Do not allow pooling of skin prep When ignition sources are used, make sure they are on the lowest setting needed

Question 41

What is asepsis?

Answer 41

The absence of pathogenic microorganisms

Question 42

What is sterility?

Answer 42

The absence of virtually all microogranisms

Question 43

What is biofilm?

Answer 43

The accumulation of bioburden, which is composed of bacteria and other biological elements Is the result of a tight adhesion of bioburden to the instrument's surface Inhibits the ability of cleaning solutions and disinfectants to effectively decontaminate the instrument Prevents successful sterilization

Question 44

What are the actions to take before transporting a patient to PACU?

Answer 44

Discard sharps into a sharps container Discard liquids per regulations and transport them in a leak-proof container Separate sharp instruments from delicate and heavy instruments Follow IFU for instrument disassembly prior to transport to decon Moisten instruments with an enzymatic pre-treatment product or cover with a water-soaked towel

Question 45

What are examples of mechanical cleaning equipment?

Answer 45

Washer-Disinfector/Decontaminator -Combines mechanical, thermal, and chemical actions -Cycles are specfic to the instruments being cleaned Ultrasonic Cleaners -Removes soil from hard-to-access areas of the instrument by caviation -Cavitation is use of high-frequency sound waves that form microscopic bubbles that become unstable and implodes, creating small vacuums that remove debris from the instrument's crevices and surfaces

Question 46

What are the characteristics of water temperature in sterilization?

Answer 46

Temperature indicators are used in decon sinks to ensure water is in appropriate temperature rage, as determined by cleaning solution manufacturer Cool water use prevents blood coagulation in instruments and helps to remove gross soil from instrument crevices, joints, and lumens -Hot water can denature blood proteins which makes blood removal more difficult Follow detergent IFU for details on amount of product needed and appropriate water temperature

Question 47

What are biological indicators (BIs)?

Answer 47

Is used to monitor the sterilizer's efficiency and effectiveness This test demonstrates whether sterilization conditions were adequate to kill non-pathogenic spores housed within the BI Negative BI indicates that the sterilization conditions were met

Question 48

What are the characteristics of packaging system weight?

Answer 48

An instrument set and container cannot weigh more than 25lbs If it weights more, it can require longer drying times Heavier sets can increase risk of injury to healthcare personnel Follow IFU for method and weight of loaner instrument or device set

Question 49

What are the considerations of BIs?

Answer 49

BI must be specific to the sterilization method BI quality tests should be performed at least weekly An ethylene oxide-specific BI is included with each EO load run A BI must be included with each sterilization load that contains one or more implants -Implant package/set is not released for use until BI test results are known A positive vial from same lot is incubated as test vial A positive BI result is immediately reported. sterilizer is not used, items processed in same sterilizer are recalled and reprocessed based on last negative BI test, further testing is done before sterilizer is cleared for use

Question 50

What determines shelf-life?

Answer 50

Shelf life of processed instruments is event-related

Question 51

What are event-related elements that impact sterility?

Answer 51

The type of packaging Storage conditions Package/tray transport methods Frequency and method of package/tray handling

Question 52

What are the critical concepts of immediate use steam sterilization (IUSS)?

Answer 52

The same cleaning and decontamination processes must be followed in the sterile processing department per manufacturer's IFU US FDA-approved rigid, enclosed sterilization container must be used Items processed by IUSS must be transported to point of use and not stored for future surgical procedures