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Flashcards in Perioperative and skin integrity Deck (59):
1

perioperative nursing involves the care of clients ___, ___, and ___ surgery and some other ___ ____
aka?

before, during and after
invasive procedures
aka operating room nursing

2

Who governs perioperative nursing practice?

AORN, joint commmission, medicaid, national priorities partnership, institute for healthcare improvement

3

These are called?
wrong patient, wrong site, wrong surgery, DVT or PE after knee or hip replacement; foreign body; surgical site infection

never events

4

Surgeries are classified by:

body system
purpose
degree of urgency
degree of risk

5

purpose...
ablative?
diagnostic?
palliative?
cosmetic?
transplant?
harvesting?

ablative-removal
diagnostic or exploratory-confirm diagnosis
palliative-relieves discomfort
reconstructive-restores fx
cosmetic-appearance improvement
transplant-replaces malfx. organ
harvesting-removing organ

6

emergent surgery happens...

within 24 hours if not immediately

7

urgent surgery happens within...

24-48 hours

8

elective surgery

has more time

9

risk? major or minor?

major-greater risk; higher infection risk
minor-lower risk

10

factors that contribute to surgical risk?

age, personal habits; allergies; type of wound; preexisting conditions; mental status; medications

11

preoperative screening tests

CBC, urinalysis (specific gravity tells hydration level), ECG (tells if heart rhythm is normal)

12

Intraoperative team...
sterile team

made up of surgeon, surgical assistant, RN 1st assist

13

Interoperative team...
clean team

anesthesiologist, CRNA, circulating nurse

14

time out

final verification of correct client, procedure and site

15

general anesthesia

most risk; loss of sensation; someone else maintaining airway; rapid unconsciousness

16

conscious sedation

IV sedation without unconsciousness; not necessarily in OR; can maintain protective reflexes

17

regional anesthesia

alert but numb; nerve block; spinal block, epidural; can't feel (interrupts nerve impulses to and from area of procedure)

18

local anesthesia

loss of pain sensation at the desired site; minor procedures

19

PACU

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

20

post op risks

surgical site infection; pneumonia; fall; pain; DVT

21

epidermis made up of

stratum corneum--outermost layer of skin
stratum germinativum--innermost layer; mostly new cells

22

what maintains the skin, repairs minor defects and preserves intravascular volume?

protein

23

what nutrition wise helps with the formation of collagen?

vit C, zinc, copper

24

what leads to increased risk for pressure and breakdown?

diminished sensation

25

what negatively affects tissue metabolism?

impaired circulation

26

medications can cause what side effects to the skin?

itching
rashing

27

Moisture leads to?

maceration--softening of the skin

28

two most common sources of moisture are?

fever and incontinence

29

fever depletes ___ and increases ___ ___

moisture
metabolic rate

30

open wound

break in skin or mucous membrane

31

closed wound

no breaks in the skin

32

acute wound

s/t; heals quicker

33

chronic wound

L/t; longer duration to recovery

34

clean wound

expected to be short duration; heal spontaneously

35

contaminated wound

open, traumatic wound or surgical incision in which a major break in asepsis occurred

36

infected wound

bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue

37

superficial wound

involve only the epidermal layer of the skin

38

partial thickness wound

extend thru the epidermis but not all the way through the dermis

39

full thickness wound

extend into the subcutaneous tissue and beyone

40

penetrating wound

wound involves internal organs

41

serous exudate

straw colored

42

sanguineous exudate

bloody drainage

43

serosanguineous

mix of bloody and straw

44

purulent

yellow, contains pus

45

regenerative healing

when the wound affects only the epidermis and dermis, regenerative/epithelial healing takes place; no scar

46

primary intention

clean surgical incision/ edges approximated; minimal scarring

47

secondary intention

wound edges not approximated; tissue loss; heals from inner layer to surface

48

tertiary intention

granulating tissue brought together; delayed closure of wound edges; increased risk of infection

49

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)

50

Braden scale based on

Total score.....= risk

sensory perception,
moisture
activity
mobility
nutrition
friction or shear

<18

51

debridement

removal of devitalized tissue or foreign material from a wound

52

sharp debridement

uses a sharp instrument to remove devitalized tissue

53

mechanical debridement

naturally remove with irrigation or hydrotherapy (book--lavage, wet to dry dressings or hydrotherapy (whirlpool))

54

enzamatic debridement

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)

55

autolysis debridement

use of occlusive moisture retaining dressing and the body's own enzymes and defense mechanisms to break down necrotic tissue; slow process

56

Jackson Pratt drainage device or Hemovac

compress device to create suction and facillitate removal of drainage

57

hydrocolloids/hydrogels

thick foamy dressing
gel dressing to retain moisture

58

binders

hold abdominal wound together

59

pressure ulcer

caused by unrelieved pressure to an area resulting in ischemia