Flashcards in Perioperative and skin integrity Deck (59):
perioperative nursing involves the care of clients ___, ___, and ___ surgery and some other ___ ____
before, during and after
aka operating room nursing
Who governs perioperative nursing practice?
AORN, joint commmission, medicaid, national priorities partnership, institute for healthcare improvement
These are called?
wrong patient, wrong site, wrong surgery, DVT or PE after knee or hip replacement; foreign body; surgical site infection
Surgeries are classified by:
degree of urgency
degree of risk
diagnostic or exploratory-confirm diagnosis
transplant-replaces malfx. organ
emergent surgery happens...
within 24 hours if not immediately
urgent surgery happens within...
has more time
risk? major or minor?
major-greater risk; higher infection risk
factors that contribute to surgical risk?
age, personal habits; allergies; type of wound; preexisting conditions; mental status; medications
preoperative screening tests
CBC, urinalysis (specific gravity tells hydration level), ECG (tells if heart rhythm is normal)
made up of surgeon, surgical assistant, RN 1st assist
anesthesiologist, CRNA, circulating nurse
final verification of correct client, procedure and site
most risk; loss of sensation; someone else maintaining airway; rapid unconsciousness
IV sedation without unconsciousness; not necessarily in OR; can maintain protective reflexes
alert but numb; nerve block; spinal block, epidural; can't feel (interrupts nerve impulses to and from area of procedure)
loss of pain sensation at the desired site; minor procedures
postanesthesia care unit; immediate postoperative phase; aka post anesthesia phase
includes: recovery from anesthesia, airway management; vital signs/LOC; dressing assessment/drainage; fluid therapy; pain control
post op risks
surgical site infection; pneumonia; fall; pain; DVT
epidermis made up of
stratum corneum--outermost layer of skin
stratum germinativum--innermost layer; mostly new cells
what maintains the skin, repairs minor defects and preserves intravascular volume?
what nutrition wise helps with the formation of collagen?
vit C, zinc, copper
what leads to increased risk for pressure and breakdown?
what negatively affects tissue metabolism?
medications can cause what side effects to the skin?
Moisture leads to?
maceration--softening of the skin
two most common sources of moisture are?
fever and incontinence
fever depletes ___ and increases ___ ___
break in skin or mucous membrane
no breaks in the skin
s/t; heals quicker
L/t; longer duration to recovery
expected to be short duration; heal spontaneously
open, traumatic wound or surgical incision in which a major break in asepsis occurred
bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue
involve only the epidermal layer of the skin
partial thickness wound
extend thru the epidermis but not all the way through the dermis
full thickness wound
extend into the subcutaneous tissue and beyone
wound involves internal organs
mix of bloody and straw
yellow, contains pus
when the wound affects only the epidermis and dermis, regenerative/epithelial healing takes place; no scar
clean surgical incision/ edges approximated; minimal scarring
wound edges not approximated; tissue loss; heals from inner layer to surface
granulating tissue brought together; delayed closure of wound edges; increased risk of infection
complications of wound healing
hemorrhage; infection; dehiscence (pops open); evisceration (emergency; things protrude thru like bowel); fistula formation (abnormal passage; most common between GI and GU tracts)
Braden scale based on
Total score.....= risk
friction or shear
removal of devitalized tissue or foreign material from a wound
uses a sharp instrument to remove devitalized tissue
naturally remove with irrigation or hydrotherapy (book--lavage, wet to dry dressings or hydrotherapy (whirlpool))
uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound (ointment with enzymes; clean first; cover with moisture containing dressing)
use of occlusive moisture retaining dressing and the body's own enzymes and defense mechanisms to break down necrotic tissue; slow process
Jackson Pratt drainage device or Hemovac
compress device to create suction and facillitate removal of drainage
thick foamy dressing
gel dressing to retain moisture
hold abdominal wound together