learning activity 5, 2nd semester Flashcards
Surgical Asepsis
methods used to eliminate ALL microorganisms including spores, and to protect an area or object from these microorganisms
Sterile Technique Guidelines/Principles
- A sterile object is sterile only when touched by another sterile object
- Only sterile objects may be placed on a sterile field
- Any sterile object out of your field of vision is contaminated. Any object held below the waist or above it is contaminated.
- A sterile object becomes contaminated by prolonged exposure to the air.
- A sterile field or object becomes contaminated by capillary action (wicking) when a sterile surface comes in contact with a wet contaminated surface.
- The edges of a sterile field or container are not considered sterile. The 1 inch border of a sterile field, towel or package is considered contaminated.
- When opening sterile kits or packages, we open away from us first, then the sides, and lastly, towards us.
Factors that affect wound healing?
Protein – Vitamin C- Zinc Obesity Wound stress Diabetes Immunocompromised Age Extent of wound Oxygenation Smoking Radiation
Types of Wounds
Abrasion
Laceration
Puncture wound
Ecchymosis (bluish discolouration of skin or mucous membrane caused by extravasation of blood into subcutaneous tissue)
How Wounds Heal
Primary Intention
Staples and Sutures
Approximated
How Wounds Heal
Secondary Intention
No sutures or staples
Wound left open- heals from inside out
Granulation tissue in wound bed
How Wounds Heal
Delayed primary Intention( Tertiary Intention)
On occasion, surgical incisions are allowed to heal by delayed primary intention where non-viable tissue is removed and the wound is initially left open.
Wound→ Inflammatory response
1st phase – Homeostasis
Bleeding stops →injured blood vessel constricts→
Platelets produce growth factor →thrombin acts on fibrinogen to form blood clot (fibrin) →stops bleeding
Blood flow ↑ causing redness and swelling
Epidermal Repair
New skin cells form at edges of wound and move across wound – more efficient if wound bed is kept moist
New epidermis fragile and lighter in color than surrounding skin.
Gradually epidermis resumes normal function and color
Strength of scar 80% of skin that has never been wounded
Complications of Wound Healing
Hemorrhage Nurses role: Monitor dressing Monitor drains Risk for is greater in 1st 24-48 hours after surgery
Hematoma
Hemorrhage under the skin
H and H ↓
↑ Pulse and BP ↓
Fistula
is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect.
Dehiscence(a wound ruptures along surgical suture)
Occurs 3-11 days after surgery
Infected wounds more prone to dehiscence
Evisceration Most serious complication Wound opens and viscera are visible or loops of bowel seen in or hanging out of the wound Client feels “ giving way” ↑ bleeding at wound Emergency
Nurse’s Role when Patient Eviscerates
Quickly place sterile saline soaked gauze or sterile towels on the wound to prevent viscera from drying out
Another nurse call Dr at the same time – client will have to go to Surgery
Keep client lying down in bed, often with knees bent
Keep warm to prevent shock and keep NPO
Take Vital signs and tell them their wound has opened and will need surgery to fix it
Keep it simple
Keep calm to prevent client from panic
Wound Dressings
First surgical dressing change usually done by surgeon then nurse will continue to change dressings as ordered
Nurses reinforce the original dressing till Doctor says to change
Doctor may order specific type of wound dressing or leave up to the nurse
Wound Assessment
REEDAS
Redness Edema Ecchymosis (superficial bleeding under the skin) Drainage Approximation of wound edges Sutures or staples are intact Also drains - condition of tissue
Wound Drainage
Serous – liquid
Sanguinous – blood
Serosanguinous – liquid & blood
Purulent – pus
Special Wound Drains
Purpose Held in place 2 main types *Gravity drains - Penrose *Suction drains - Jackson – Pratt or JP drain - Hemovac
Nurse responsibilities with surgical drains
Ensure suction exerted All connection points intact Tubing not kinked Assess drainage Record on I & O sheet
Contraindicated solutions
Hydrogen peroxide (H2O2) Betadine
Types of Dressing Materials
Gauze Transparent Hydrocolloid Tape – Types Montgomery Straps/Ties
Documenting –
2 parts
Observation of wound (REEDAS)
The dressing
Heat and Cold Applications
Heat Dry or moist heat Dry – heating pad Moist Common uses – washcloth Soaks and sitz baths Aquathermia – K pad Tepid or lukewarm sponge bath
Cold Applications
Action
Compresses
Hypothermia Blanket
Wound Classifications
Cause: intentional, unintentional
Skin integrity: open, closed, acute, chronic
Depth: partial thickness, full thickness
Cleanliness: clean, contaminated, infected
Duration: acute vs. chronic
Colour: red, yellow, black & mixed (applied to any wound healing by secondary intention)
Pressure Ulcers: Pathogenesis
Pressure intensity
Pressure duration
Tissue tolerance
Pressure Ulcers: Causes
Friction Shearing force Moisture (maceration) Impaired mobility Altered level of awareness Impaired sensory perception
Stages of Pressure Ulcer Formation
Stage I: persistent red, blue, or purple tones; no open skin areas
Stage II: partial-thickness skin loss; presents as an abrasion or blister
Stage III: full-thickness skin loss with damage or necrosis of subcutaneous tissue; presents as a deep crater
Stage IV: full-thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, other structures
Unstageable: full-thickness tissue loss in which the base is covered by slough (dead tissue yellow, tan, grey, green or brown) or eschar (dead matter cast off the skin surface especially after a burn, crusty or scabbed tan, brown or black) or both, in the wound bed
The three phases of Wound Healing:
Inflammatory phase
Proliferative phase
Remodelling phase
Complications of Wound Healing
Hemorrhage—shock Infection Dehiscence Evisceration Fistula formation
Assessment
Skin: colour, temperature, turgor, integrity Risk for pressure ulcers: Braden scale Mobility Nutritional status Exposure of skin to body fluids
Assessment of Wounds
Emergency Setting
Abrasions Lacerations Punctures Appearance Amount of bleeding Size
Assessment of wounds
Stable setting Appearance: size, healing Character of drainage: serous, sanguineous, serosanguineous, purulent Tools Drains Closures: staples, sutures Palpation of wound Wound cultures: aerobic, anaerobic Pain
Nursing Diagnosis: Wounds
Risk for infection Imbalanced nutrition: less than body requirements Pain Impaired skin integrity Impaired tissue integrity
Goals and outcomes Wound improvement within 2 weeks No further skin breakdown Increase in caloric intake by 10% Setting priorities Continuity of care
Prevention of pressure ulcers
Topical skin care
Positioning
Therapeutic beds and mattresses
Education
Dressing Changes
- Administer required analgesic
- Explain steps of procedure to client
- Gather all necessary supplies
- Prepare sterile field, as indicated
- Remove old dressing, assess area, and provide necessary care using appropriate aseptic technique
- Answer client’s questions and document care provided
Wound Care
Cleansing skin and drain sites Wound irrigations Suture/staple care and removal Drainage evacuation Comfort measures
Application of Bandages and Binders
Inspect underlying skin Cover exposed wounds Assess condition of dressings Assess skin of areas distal to bandage Use appropriate technique to apply
Sterile gloves must be worn when touching sterile dressing supplies or the wounds inner surface. T or F
True
It is not necessary to wash your hands prior to putting on sterile gloves. T or F
False
Should dominant or non-dominant hand be gloved first?
Dominant
Once sterile gloves are on both hands, it is important to maintain “sterile to sterile technique”. T or F
True
Sterile Gloves should be changed if:
a. sterile gloves touch a clean item
b. sterile gloves touch a contaminated item
c. glove tears
d. b and c
e. b only
f. all of the above
f. all of the above
When applying sterile gloves, it is important that the package of glove be placed on a surface that is:
a. eye level
b. waist level
c. flat
d. hip level
b. Waist level
Gloves should be removed and disposed of one at a time to avoid contamination. T or F
False
Wound infection is the second most common hospital related infection. T or F
True
When sterile gloves are worn, it is best to:
a. interlock the fingers and keep the gloved hands at eye level
b. interlock the fingers and keep the gloved hands at waist level
c. keep hands at sides
b. interlock the fingers and keep the gloved hands at waist level
List four signs of possible latex sensitivity.
itching hives rhinitis wheezing changes in vitals
List four factors that effect wound healing
age chronic disease smoking nutrition obesity medications
When palpating the skin around the wound, assess for?
Pain
edema
skin temperature
Serous
clear, watery plasma
purulent
thick, yellow, green, or brown drainage with odour
sanguineous
bright red, indicates frank bleeding
serosanguineous
pale, red, watery drainage
What factors facilitate or inhibit wound healing?
(1) Adequate oxygenation
(2) Adequate rest or local immobilization
(3) Sufficient blood supply
(4) Proper nutrition
(a) Nutrients are needed for wound repair and prevention of infection
(b) Adequate wound healing is dependent upon the availability of essential nutrients
Factors that impair wound healing
(1)Age - causes slower regeneration of tissue
-Vascular changes impair circulation to wound site
-Formation of antibodies and lymphocytes is reduced
-Scar tissue is less elastic
(2) Malnutrition
Stress from burns or severe trauma increases nutritional requirements
Interventions - Provide balanced diet rich in protein, carbohydrates, lipids, vitamins A and C, and minerals
(3) Impaired oxygenation
-Low arterial oxygen tension alters synthesis of collagen and formation of epithelial cells
-If local circulating blood flow is poor, tissues fail to receive needed oxygen
( 4) Obesity
Fatty tissue lacks adequate blood supply to resist bacterial infection and deliver nutrients and cellular elements
(5) Smoking
-Reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation
-May increase platelet aggregation and cause hypercoagulability
-Interferes with normal cellular mechanisms that promote release of oxygen to tissue
(6) Presence of infection
(7) Drugs
-Steroids reduce inflammatory response
- Anti-inflammatory drugs suppress protein synthesis, wound contraction, epithelialization, and inflammation
-Prolonged antibiotic use may increase risk of superinfection
-Chemotherapeutic drugs can depress bone marrow function, number of leukocytes, and inflammatory response
(8) Diabetes mellitus
-Causes small blood vessel disease that impairs tissue perfusion
- Causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues
-Alters ability of leukocytes to perform phagocytosis and also supports overgrowth of fungal and yeast infection
What are the various categories of wounds?
Closed wound injury-
(1) Contusion - Hematoma beneath unbroken skin because of small vessel ruptures
(2) Crush injuries - Overlying skin may remain intact, injury to multiple tissues, muscle or bone
Open wound injury
(1) Abrasions - Partial thickness skin loss
(2) Lacerations - Break in skin of varying depth
(3) Avulsion - Full thickness skin loss, degloving or flap injuries are avulsions
(4) Amputations - A part of the body is partially or completely severed or torn from the body
(5) Punctures/ penetrations - Caused by a foreign object that enters the body, underlying damage can be extensive
(6) Bite - Breakage of the skin caused by animal or human teeth, all bites are considered contaminated
