Skills Unit 2 Flashcards
(242 cards)
1
Q
What is surgical asepsis
A
Refers to those practices that keep an area or object free of all microorganisms; includes practices that destroy all micro organisms and spores (ie;sterile equipment,foley, putting anything into an opening
2
Q
Bacteria
A
Are by far the most common infection causing microorganisms; can be transported through air, water, food, soil, body tissues and fluid and inanimate objects
3
Q
Viruses
A
Consist primarily of nucleic acid and therefore must enter cells in order to reproduce
4
Q
How is bacteria transported
A
Air water food soil body tissues fluid and in animate objects
5
Q
Fungi
A
Includes Yeast and molds
6
Q
Parasites
A
Live on other living organisms
7
Q
Colonization
A
is the process by which strains of Microorganisms become resident flora , may grow and multiple but does not cause disease
8
Q
When does infections occur
A
When newly introduced or resident micro organisms succeed In invading a part of the body where the hosts defense mechanisms are ineffective and the pathogen causes tissue damage (((becomes a disease)))
9
Q
A local infection
A
Is limited to the specific part of the body where the micro organisms remain
10
Q
Systemic infection
A
Spread and damage different parts of the body
11
Q
Bacteremia
A
Culture of the persons blood reveals micro organisms
12
Q
Where do nosocomial infections originate
A
Hospital
13
Q
Endogenous source
A
From the hospital environment
14
Q
Exogenous source
A
From the staff
15
Q
Chain of infection
A
Etiologic agent, reservoir, portal of exit, Mode of transmission, portal of entry, susceptible host
16
Q
non specific defenses
A
Protect person against all micro organisms , regardless of prior exposure
17
Q
Three types of nonspecific defenses
A
Inflammation vascular and cellular responses and exudate production
18
Q
What is inflammation
A
Local and nonspecific defensive response of the tissue to an interest or infectious agent
19
Q
5 signs of inflammation
A
Pain ,swelling ,redness ,heat and impaired function of the part
20
Q
Three stages of inflammatory response
A
1st stage vascular and cellular responses 2nd stage exudate production 3rd stage reparative phase
21
Q
specific defenses
A
Antibody mediated defenses and cell mediated defenses
22
Q
Factors increasing susceptibility to infection
A
Hereditaty, age, diseases, medications, nature, number and duration of stress
23
Q
disinfection vs. sterilization
A
antiseptics, and disinfectants
24
Q
antiseptics
A
agents that inhibit growth of some microorganisms
25
disinfectants
agents that destroy pathogens other than spores
26
different ways to sterilize
moist heat, gas ,boiling water,radiation
27
antiseptic
chemical preparation
28
standard precautions
all body fluids except sweat
29
standard precautions
1)hand hygiene 2) use of PPE 3)safe injection practices 4)respiratory etiquette 5) safe handling contaminate equipment
30
Respiratory hygiene
Airborne, Droplet, Contact
31
airborne
negative air pressure ex. TB, N95 mask, don't move pt unless necessary, if necessary put mask on pt
32
droplet
diptheria, mumps, rubella pneumonia ( wear mask if working within 1-3 ft of pt, place mask on client if leaving room
33
contact
private room, wear gloves , remove before leaving clients room, wear a gown if possibility of contact with infected surfaces or items, or if client is incontinent
34
compromised client
the harm we can do to them always standard precations ie. cancer or burn pt
35
oreder to put on ppe
gown, face mask, eyewear, gloves
36
remove soiled ppe
undo gown if soiled, gloves, eyewear, gown, mask
37
transporting infectious clients
avoid at all costs, if needed mask client and cover infections or open wounds
38
psychosocial needs of isolation clients
self esteem decreases, sensory deprived
39
intentional wounds
clean, clean contaminated
40
unitentional wounds
contaminated, dirty or infected
41
clean wounds
uninfected, minimal inflammation primarily closed wounds,
42
clean-contaminated wounds
surgical wounds, gi, respiratory, genital,urniary tract entered
43
contaminated wounds
open, fresh, accidental and surgical involve major break in sterile technique
44
dirty infected wounds
contain dead tissue with evidence of clinical infection
45
pressure ulcer etiology
heels, coccyx, elbows, hips ears nasal
46
risk factors for pressure ulcers
friction shear, immobility, inadequate nutrition, incontinence, decrease mental status, diminished sensation, excessive body heat, advanced age, chronic medical conditions, transfer technique, obese, body build
47
non stageable
v (stage five) hard necrotic need chemical or debrided
48
stage one pressure ulcer
nonblanchable erythema (intact)
49
stage II pressure ulcer
partial thickness skin loss (skin impaired)
50
stage III pressure ulcer
full-thickness skin loss (impaired tissue integrity) undermining-tunneling present
51
stave IV pressure ulcer
full thickness-tissue necrosis-damage to muscle, bone, tendon and joint capsules, undermining, tunneling
52
undermining
skin intact, tissue disenitigration
53
tunneling
creates dead space
54
braden scale
23 is max below 18 have to do something about
55
primary wound healing
where tissues have been approximated, minimal or no tissue loss
56
secondary wound healing
extensive and involves considerable tissue loss: ex: stage II pressure ulcer
57
tertiary wound healing
left open 3-5 days close with staples, sutures, and adhesive skin closures
58
inflammatory phase
begins immediately after injury and lasts 3-6 days
59
proliferative phase
second phase in healing, extends from day 3/4-21 after injury. Fibroblasts synthesize collagen.
60
maturation phase
begins on about day 21 and can extend 1-2 years after injury. Wound is remolded and contracted.
61
exudate phases
sanguenous, serosanguineous, serous
62
serious exudate
clear portion of blood
63
purulent exudate
thicker because of pus
64
sanguineous exudate
large amounts of red blood cells ie: open wounds
65
mixed types of exudate
seroanquineous-clear and blood tinged drainage
| purosanguineous-pus and blood
66
hemorrhage
massive bleeding; ie; dislodged clot, slipped stitch
67
risk for hemorrhage is greater when
24-48 hours after surgery
68
if clients dressing is increased in bleeding
dont remove current bandage, appy another bandage, assess vitals, call physician
69
how do you confirm infection
wound culture
70
infection
suggested by a change in wound color, pain, odor or drainage
71
how does infection occur
microorganisms colonize
72
when does a surgical infection become most apparent
2-11 days postoperatively
73
dehiscence
partial or total rupturing of a sutured wound; usually involves abd wound
74
evisceration
protrusion of the internal viscera through an incision
75
factors in client with infections
altered mental status, fever, cbc with increase wbc chills.
76
wound culture
sensitivity and bug
77
local problems with infections
heat, swelling, pus
78
how to take out sutures/ staples
every other one; if suspected infections;order for culture, wound check, vitals,
79
dehiscence risk factors
vomiting, dehydrations, coughing, poor nutrition, multiple trauma
80
secondary intention
edges cannot be approximated
81
if dehiscence or evisceration
moist sterile dressing, in bed with knees bent notify surgeon immediately.
82
who heal quicker
healthy and young
83
nutritions factors affect wound healing
more than 1500-2000 ml per day for moisteness
84
lifestyle factors affection wound healing
exercise, hygiene, smoking is number 1 problem.
85
medications affecting wound healing
anti-inflammatory drugs, antibiotics, antineoplastics (chemotherapy)
86
untreated wounds
control bleeding, prevent infection, assess for shock
87
if infected area is dirty what should you do before you get culture
clean it
88
Treated wounds
assess progress of healing, drainage watching for undermining, size and appearance
89
Pressure ulcers
locations, size, undermining, stage, color, integrity infection
90
nursing history and physical assessment
past history and skin disease,fast healers? slow healers?
91
Laboratory Data
a decreased leukocyte, delay healing, decreased hemoglobin means decreased oxygen
92
first thing to do when obtaining a wound culture
cleanse wound
93
how do you obtain the aerobic wound culture
clean first, back and forth from sides or base
94
how to collect anarobeic culture
put deep into the wound and as soon as done put into tube with an oxygen free gas or gel environment
95
what kind of pressure ulcer is risk for impaired skin integrity
stage I
96
impaired skin integrity
stage II
97
impaired tissue integrity
stage 3/4
98
planning
explain diet, hygiene teaching and document our teaching
99
moist wound beds
heels 3-5 times faster
100
fluids/nutrition
at least 2500 ml/day unless contraindicated vitamin b,c, iron and calories
101
infection prevention
prevent micro organisms, and blood borne pathogens likely colonized with own bacteria but doesn't mean infected
102
positioning
increased activity helps, keep pressure off wound every 2 hrs turned
103
prevention of pressure ulcers
nutrition-monitor weight and lab work
104
hygiene
prevent pressure ulcers, avoid skin trauma, no massage over bony areas
105
avoid skin trauma
no wrinkles of beds, no more then 30 degrees for head of bed, frequent position changes
106
what to avoid
donuts
107
all pressure ulcers
stay at stage 3
108
Red
healthy granulated tissue, protect and cover it
109
yellow
cleanse
110
black
debride
111
who does debridement
specially trained nurse or physician
112
debridement-sharpe
separating and removing dead tissue
113
autolytic debridement
Ideal!! takes long, less damage to surrounding tissue lets your own body heal itslef
114
chemical debridement
dont put on healthy tissue
115
mechanical-debridement/scrubbing
damp-damp dressings
116
transparent dressings
prevent skin breakdown, provide protection against contamination, pressure ulcers stage I, can stay on longer than a week
117
hydrocolloid
autolytic debridement, partial thickness wounds, pressure ulcers stage II-IV
118
hydrocolloid
waterproof adhesive wafers, be worn for up to a week, two layers, absorbs exudate autolytic debridement
119
montegomery straps
used for wounds requiring frequent dressing changes
120
alginates
beads or granules, absorbs up to 20 times their weight in exudate,pressure ulcers,
121
hydrogels
requires secondary occlusive dressing, pressure ulcers,liquefy necrotic tissue
122
irrigation
4-15 psi, b/c of breakdown in skin, 30-60ml syringe w/ 19g needle catheter=8psi
can also use oral water pic at lowest setting
123
cleansing wounds
can use normal saline, lactated ringers, and antibiotics solutions
124
gauze packing
using damp-damp technique that require debridement
125
What is medical asepsis
Includes all practices intended to confine a specific microorganism to a specific area limiting the number, growth, and transmission of micro organisms.
126
The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following
block the portal of exit from the reservoir
127
which is the most effective nursing action for preventing and controlling the spread of infection
thorough hand hygiene
128
In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform
follow standard precautions in all interactions with the client.
129
when caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment
goggles
130
while applying sterile gloves (open method) the cuff of the first glove rolls under itself about 0.5 cm(1/4) which is the best action for the nurse to take?
leave the cuff rolled under
131
The nurse evaluates the chart of a 65 y/o client with no apparent risk factors and concludes that which immunizations are current?
flue shot every year, has not recieved a or b vaccine
132
A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be
risk for infection
133
After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred?
"we must wash or peel all raw fruits and vegetables before eating"
134
What is considered unsterile
below the waist, above the neck, higher than 2 inches above the elbow, below table and the back
135
The nurse determines that a field remains sterile if which of the following conditions exist?
Sterile items are 2 inches from the edge of the field.
136
Medical aseptic practices
limit the number, growth and transmission of micro organisms
137
Surgical aseptic practices
keep an area or objects free of all microgranism
138
Factors that contribute to nosocomial and health care associated infection risks are
invasive procedures, medical therapies, the existence of a large number of susceptible individuals, inappropriate use of antibiotics and insufficient hand hygiene after client contact and after contact with body substances
139
Immunity
is active or passive, can be naturally or artificially induced, and is the specific resistance of the body to infectious agents
140
Types of nonspecific Defenses
Inflammatory Response, Vascular and Cellular Responses, Exudate Production, and Reparative Phase
141
Types of Specific Defenses
Antibody and Cell mediated defenses
142
Antibody-Mediated Defenses
active immunity (vaccines) and passive immunity(nursing mother)--acquired
143
Cell Mediated Defenses is lost
a person can become defenseless against most viral, bacterial, and fungal infections, like with HIV
144
Every Rule permits moms pimp hand
Etioligic, reservoir, portal of exit, mode of transportation, portal of entry, susceptible host
145
sterilization
a process that destroys all microorganisms, including spores and viruses.
146
signs of systemic infection
Fever, increased pulse & resp rate, loss of energy, anorexia, NV
147
Types of wounds
Clean wounds, Clean-contaminated wounds, Contaminated wounds, Dirty or infected
148
primary intention
minimal or no tissue loss
149
second intention
pressure ulcer, involves considerable tissue loss
150
tertiary intention is
wounds that are left open for 3-5 days, clean it and let it heal by itself
151
complications of wound healing
hemorrhage, infection,
152
Stage 1
nonblanchable intact skin erythema signaling potential ulceration
153
Stage 2
partial-thickness skin loss, impaired skin integrity
154
Stage 3
full-thickness skin loss ; impaired tissue integrity---involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
155
Stage 4
full-thickness skin loss with ; tissue necrosis ---or damage to muscle, bone or supporting structures, such as tendon or joint capsule. Underminig and sinus tracts may also be present
156
Unstageable/Unclassified
full thickness skin or tissue loss-depth unknown: Actual depth of the ulcer is completely obscured by slough/eschar in the wound bed
157
Suspected deep tissue injury--depth unknown
purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear.
158
Clean wound
uninfected; closed; minimal inflammation
159
Clean-contaminated wound
surgical;--resp;gi;ut has been entered--no evidence of infection
160
contaminated wounds
open, fresh accidental; & surgical involve break in sterile technique; or spillage from gi tract; have evidence of inflammation
161
Dirty or infected wounds
dead tissue; clinical infection; purulent drainage
162
Risk factors contributing to pressure ulcers
Friction and shearing, immobility, inadequate nutrition, decreased mental status, diminished sensation, excessive body heat, advanced age, chronic medical conditions,
163
Intentional wounds
Clean, & clean-contaminated
164
Unintentional wounds
Contaminated, & Dirty infected
165
Braden scale
23 max ----anything below 18 at risk
166
Primary intention
minimal or no tissue loss, usually closed seal lacerations or incisions
167
Secondary Intention
extensive, tissue loss, edges cannot be approximated; pressure ulcer
168
Tertiary intention
left open 3-5 days to allow edema or infection to resolve or exudate to draid and are then closed w/ sutures
169
Complications of wound healing
Hemorrhage, Infection, Dehiscence with Possible Evisceration
170
Hemorrhage
Apply pressure dressing, vitals, call
171
Infection
Wound culture, vs, ^ WBC call
172
Dehisence
Cover, Sterile dressing, VS, call
173
Evisceration
Lg Sterile dressing w/ NS knees bent, VS, Call
174
Factors affecting wound healing
Developmental, Nutrition, Lifestyle, Medications, Stress!!!
175
Untreated wounds
seen shortly after injury
176
treated wounds
assess progress of healing
177
Risk for pressure ulcer
over bony prominence
178
Aerobic
grows only in air, normally on surface of wound
179
Anaerobic
grows in absence of oxygen, found deep in wounds
180
Risk for impaired skin integrity
Stage I, vulnerable to alteration in epidermis/dermis may compromise health
181
Impaired Skin Integrity
Stage II, altered epidermis/dermis
182
Impaired Tissue Integrity
Stage III,IV --damage to mucus membrane
183
Support wound healing
moist wound beds, fluids and nutrition, Infection prevention, Positioning
184
wound is likely colonized with patients own bacteria
but does not mean its infected
185
Red
protect and cover it
186
Yellow,
Cleanse
187
Black
Debride
188
Transparent film
adhesive film, protect contamination,m maintain moist, pressure ulcer stage 1,
189
Hydrocoloids
waterproof adhesive wafers, pastes or powders, absorbs exudate, autolytic debridement stage II-IV can be on for up to 7 days;contain wound odor; should not be used for infected wounds
190
Hydrogels
Glycerin or water based nonadhesive, requires secondary occlusive dressing, liquefy necrotic tissue or slough, pressure ulcers, partial thickness wounds
191
Alginates
nonadherent dressing of powder, beads or granuels absorb up to 10 times their weight, provide a moist wound surface, pack wounds, pressure ulcers, wounds undergoing chemical debridement
192
Mechanical debridement
scrubbing--damp-to-damp dressing
193
Chemical debridement
Collagenase enzyme agents;selective
194
Autolytic debridement
hydrocolloid and clear absorbent acrylic
195
Sharp debridement
scalpel or scissors to separate and remove dead tissue
196
Irrigation
sterile technique, NS, LR, &antibiotic solution, 4-15 psi, 30-60 ml syringe w/19 g needle = 8psi / oral water pic at lowest setting
197
Montgomery straps
are used for wounds requiring frequent dressing change
198
Bandaging
Normal position, pad between bony prominences, distal->proximal, even pressure, leave end of body part exposed, cover dressings with bandages at least 5cm
199
Circular bandage
used to anchor bandages, not normally right over wound b/c of discomfort
200
Spiral turns
body parts that are fairly uniform in curcumference--upper arm or leg
201
Spiral reverse
cylindrical parts of body that are not uniform in circumference; lower leg or forearm
202
Recurrent turns
cover distal parts of the body, finger, skull, or stump of amputation
203
Figure eight
elbow, knee, ankle
204
Binder
support large areas such as abdomen and chest
205
Arm sling
flex elbow at 80, thumb facing up,
206
Heat causes
vasodilation, ^^capillary permeability, cellular metabolism, inflammation, sedative effect
207
Cold causes
Vasoconstriction, Decrease capillary permeability, cellular metabolism, slows bacterial growth, decrease inflammation, local anesthetic effect
208
Body part
the back of the hand & foot are not temp sensitive. (wrist, forearm, neck and perineal are temp sensitive)
209
Size of exposed body part
larger the area exposed heat and cold the lower the tolerance
210
Individual tolerance
the very young and old generally have low tolerance, individuals who have neurosensory impairments may have a high tolerance but the risk of injury is greater
211
Length of exposure
people feel hot and cold applications most while the temperature is changing. after time tolerance increases
212
Intactness of skin
injured skin areas are more sensitive to temperature varation
213
Muscle spasm
Heat: relax and increase contractility
Cold: relax decrease contractility
214
Rebound Phenomenon
heat max vasodilation 20-30 mins beyond 30 brings tissue congestion
215
Inflammation
Heat: increase blood flow;softens exudates
Cold: vasoconstriction decrease cap permeability, decrease blood flow, slows cellular metabolism
216
Pain
Heat: Releaves pain, promote muscle relax, increase circulation, promote psychological relaxation and feeling of comfort acts as a counterirritant
Cold: Decrease pain by slowing nerve conduction rate and blocking nerve impulses' produces numbess, acts as a counterirritant, increases pain threshold
217
Contracture
Heat: Reduces contracture and increases joint ROM by allowing greater distention of muscles and connective tissue
No effects of cold
218
Joint Stiffness
Heat: Reduces joint stiffness by decreasing viscosity of synovial fluid and increasing tissue distensibility
No effect on cold
219
Traumatic Injury
No effects of Heat
| Cold: decreases bleeding by constricting blood vessels; decreases edema by reducing capillary permeability
220
Electric heating pads
can burn if setting too high, body is dry,use with preset heating switch , do not place pad under client, heat will not dissipate and client may be burned
221
Sitz bath
soak clients perineal or rectal are, temp 104-110 degrees, 20 mins, provide support for client feet, can prevent pressure on backs of the thighs, observe client
222
Cooling sponge bath
reduce fever promotes heat loss through conduction and vaporization. temp must be over 104, antipyretic meds, temp range 80-98 degrees, sponge face, arms, legs, back and buttocks,ice bags forehead and axilla and groin, 30 mins, VS every 15 mins
223
Ted hose
purpose: circulation
Measure: both legs from heel to gluteal fold(thigh hight)/heel to popliteal space (knee high) and circumference of each calf and thigh at widest point
application: before out of bed, if up elevate legs for 15-30 mins
224
Asepsis is the freedom from
disease causing microorganism
225
Your client has a Braden scale score of 17. Which is the appropriate nursing action
Implement a turning schedule; the client is at increased risk of skin breakdown
226
Proper technique for performing a wound culture includes which of the following
Cleansing the wound prior to obtaining the speciment
227
A client has a pressure ulcer with a shallow, partial skin thickenss, eroded area but no necrotic areas. The nurse would treat the area with which dressing?
Hydrocolloid --protects shallow ulcers and maintains an appropriate healing environment
228
Alginates
used for wounds with significant drainage
229
Dry gauze
will stick to new granulation tissue causing more damage
230
Thirty minutes after application is initiated the client request that the nurse leave the heating pad in place the nurse explains the following to the client
Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation)
231
Which statement, if made by the client or family member, would indicate the need for further teaching?
If mu father cannot turn himself in bed, I should help him change position every 4 hours.
232
Your client is only comfortable lying on the right or left side (not on the back or stomach)List four potential sites for pressure ulcers
Hips, heels, shoulder, Knees
233
An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is
Impaired skin integrity--
234
Which of the following are primary risk factors for pressure ulcers
Low-protein diet, fever, lengthy surgical procedures
235
Which of the following items are used to perform wound irrigation
clean gloves, sterile gloves, 60-mL syringe
236
Which of the following indicates proper use of a triangle arm sling?
The knot is placed on either side of the vertebrae of the neck
237
Etiologic agent
cleaned and disinfected or sterilized before use, educate about appropriate methods for cleaning disinfecting and sterilizing,
238
Reservoir
Change dressing or bandage when soiled/wet, moist dressing are ideal for microorganisms to grow/multiply, hygiene important, dispose of things properly, overexposure promotes bacteria growth
239
Portal of exit from the reservoir
Avoid talking, coughing etc. over open wounds or sterile fields, limits the number of microorganisms to escape from resp tract
240
Method of transmission
Hand hygiene, gloves and gowns, masks and eye protection when necessary, soiled materials in moisture proof bags,
241
Portal of entry
aseptic technique for invasive procedures, sterile technique when exposing open wounds or dressing,
242
Susceptible host
Skin and mucous membranes protect against invasion, balanced diet, immunizations, stress management
