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Nursing 220 > Surgical Asepsis and Wound Care, Fractures, Surgery Care > Flashcards

Surgical Asepsis and Wound Care, Fractures, Surgery Care Flashcards

1
Q

What is HAI or nosocomial infection?

A

Infection given to patient in hospital. Influenced by HCP having direct contact, type and number of invasive procedures, length of stay.

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2
Q

What is medical asepsis?

A

Clean technique. Reduce and prevent spread of microorganisms like using standard precautions.

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3
Q

What is it called when you use sterile technique and its the procedure to eliminate microorganisms? It’s needed when breaking skin barriers.

A

Surgical asepsis.

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4
Q

What are the 7 principles of surgical asepsis?

A
  1. Sterile remain sterile when touched by sterile
  2. Sterile objects can be placed on sterile field- sterile objects kept in clean/dry areas, sterile packages must remain dry and intact
  3. Sterile object/field out of range of vain and object held below someone’s waist is contaminated (keep field in view at all times and don’t turn back)
  4. Sterile object/field becomes contaminated by long exposure to air (decrease talking, sneeze, laugh, cough, hold items close to sterile field)
  5. When sterile surface contacts with wet contaminated surface, sterile object and field is contaminated by capillary action (make sure surface below sterile field is dry, avoid apply when pouring, moisture seeping though sterile package=microorganisms travel to sterile object)
  6. Fluids flows in direction of gravity (keep instruments lower than handles, hands above elbows-surgical scrub)
  7. Edges of sterile field are contaminated (2.5 cm border)
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5
Q

What is an acute wound?

A

wound that heals in timely manner. Could be because of trauma or incision. Wounds are easily cleaned and repaired. wound edges intact/approximated.

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6
Q

What is chronic wound?

A

Would that fails to heal in timely manner. Like vascular compromise, chronic inflammation. Continued expose to insult will impeded wound healing.

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7
Q

What do we cleanse wounds with?

A

Normal saline

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8
Q

What is debridgement of healable wound?

A

Remove the non-viable tissue.

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9
Q

What is the appropriate moisture balance for wounds?

A

Not too wet and not too dry.

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10
Q

What is primary intention healing?

A

Minimal and no tissue loss, wound approximated, minimal scar formation.

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11
Q

What is secondary intention healing?

A

Tissue loss, edges not approximated, wound filled by scar (connective tissue), risk of infection greater, takes longer to heal.

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12
Q

What is tertiary intention healing?

A

Wound left open for several days then closed surgically .

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13
Q

What are the 4 stages in wound healing?

A
  1. Hemostasis- within minutes of injury body send platelets to site to aggregate/vasoconstrcit blood vessels, starts clotting
  2. Inflammatory- body protective response to injury, last 2-4 days, histamine released causes vasodilation and WBC migrate, leukocytes ingest bacteria and dead cells
  3. Proliferative- last 3-24 days, new blood vessel forms, collagen contracts and decreased wound bed size to speed healing, epidermal cells migrate over granulation tissue
  4. Maturation/remodel- up to 2 yrs, surface of wound look healed , collagen production continues, scar formed
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14
Q

What factors affect wound healing?

A

Nutrition, age, lifestyle, medications, contamination, colonization, and infection.

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15
Q

True or false: you need practitioners order to change dressings?

A

True

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16
Q

what are the types of wound drainage?

A

Serous- clear, watery plasma
Purple t- thick, yellow, green, brown (infection)
Serosanguineous- pale, red, watery, mixture of clear/red fluid
Sanguineous- bright red, indicates active bleeding (fresh)

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17
Q

What are the % for amount of drainage?

A

none- 0
scant- less 5% soiled
small 5-25%
moderate 25-50%
large 50-75%
saturated >75%

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18
Q

What does REEDA stand for?

A

How to assess simple wounds. Redness, ecchymosis (bruise), edema, drainage, and approximation.

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19
Q

How do we cleanse wounds?

A

Clean from least to most contaminated. 5 swiped with different gauze with gentle friction. Swiped over incision line first then beside.

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20
Q

What are wound drains?

A

Device placed near wound if large amount of drainage is anticipated. Should assess the drainage for colour, consistency, amount, blockages. Sometimes they are stitched and held in place with suture. Also assess peri drain skin for redness.

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21
Q

How do we clean drains?

A

Clean by circling around sit with gauze. Use different gauze for each swipe. Clean the incision before the drain site.

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22
Q

What is a penrose drain?

A

Open drain that allows fluid to flow passively from area inside to outside the body. Has safety pin that sterile on outside of drain.

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23
Q

When removing the drain, what do you have to make sure that’s intact?

A

The tip so it doesn’t leave pieces inside the patients body.

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24
Q

What is the hemovac drain?

A

Closed vacuums drain that holds a lot of fluid (400-500 mL). It uses suction and often used for bone surgery.

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25
Q

What is the jackson pratt drain?

A

Closed vacuum drain that holds 90-100 mL of fluid. Works on suction principle to pull out fluid. If ball is compressed that means suction is engaged.

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26
Q

How to put on and take off sterile gloves?

A

Start with dominant hand and slip it in. Then left hand slip it but put fingers of R hand in cuff to help put it over. Then fix cuffs and fingers. Take off by pinch outside of glove and then take fingers of bare hand and slide those under remaining glove/turn it inside out. HH

27
Q

What is the process for simple dressing change?

A
  1. Introduction, check doctors orders, expose wound area
  2. Prepare sterile field, clean gloves, remove dressing away from you and G tweezers remove inner dressing
  3. New clean gloves, use sliver tweezers and saline gauze to clean wound top to bottom, least to most infected, dry
  4. Inspect wound using REEDA
  5. Use silver tweezers to put on new gauze/ABD pad, secure with tap, sign the tape (initials, date, time)
28
Q

How do we set up sterile field?

A
  1. Table at waist level, HH, clean workplace
  2. Open tray away from you, pull out G tweezers/get sterile drape (touch 2.5 cm border), place shiny side down with hands close to body
  3. Use G tweezers to place silver tween sets on edge, set up garbage bag, add gauze
  4. Add sterile solution to soak gauze (wet stuff by garbage)
29
Q

Wound staple removal?

A
  1. Check doctor orders and explain procedure, expose area
  2. Set up sterile field including staple remover, steri-strips if ordered
  3. Gloves, Remove top dressing (assess for drainage) inner dressing with G tweezers, get rid of gloves
  4. Clean incision with new clean gloves (5 swipes), dry if wet
  5. Assess using REEDA
  6. Remove staple with cutter parallel to skin (put under staple and lift up, do every other then reassess approximation, then remove leftover)
  7. Clean/dry incision again
  8. Apply steer strips with gloves if ordered
  9. Cover in ions with 2 4x4 gauze, ABD pad, tape
30
Q

Wound suture removal?

A
  1. Steps up to removal are the same as staples
  2. Clean gloves, use tweezers to grasp knot and blade to cut underneath, pull out knot across, remove every other
  3. Reassess approximation, then remove more
  4. Clean and dry
  5. Steristrips if ordered, and new dressing
31
Q

What is the Braden scale?

A

Out of points, lower score is more dangerous. categories are nutrition, fiction/shear, sensory perception, moisture, activity, and mobility.

32
Q

Stage 1 of pressure injury?

A

Intact skin with non-blanchable (doesn’t turn white) redness

33
Q

Stage 2 pressure injury?

A

Partial thickness loss of dermis, looks like shallow ulcer, red/pink bed, could be intact or open blister, no slough (decaying tissue that’s yellow).

34
Q

Stage 3 pressure injury?

A

Full thickness tissue loss, exposed bone/tendon/muscle, slough and escar may be present, often undermining and tunneling, possible odour and drainage.

35
Q

Unstageable presssure injury?

A

Full thickness tissue loss, base of ulcer covered by slough and eschar (black dead tissue). Extent of tissue damage can’t be confirmed.

36
Q

What acronyms do we use to assess complex wounds?

A

MEASURE. Measure (length, width, depth), Exudate (amount, type, is there odour), Appearance of wound bed (tissue type- black, grey, brown, yellow, red/pink), Suffering (scale 0-10), Undermining (tissue destruction extends under intact skin along wound margin, tunnelling- destruction occurring downwards), Re-evaluate (re-assess wound), and Edge (appearance of edge and surrounding skin).

37
Q

What method do we use to assess the wound?

A

Clock method. Patients head is top of clock and patients feet is bottom of clock.

38
Q

What is negative wound pressure therapy?

A

Applies localized negative pressure to surface and margins of wound to enhance healing, It’s a special dressing changed every 3-5 days.

39
Q

What do we document for wounds?

A
  1. What we did and why
  2. Pain assessment- pre/intra/post
  3. Dressing removal describes
  4. What we did to the wounds
  5. Assessment using REEDA or MEASURE, drainage present? cleansed?
  6. Dressing application technique
  7. Patient tolerance and teaching
40
Q

How to irrigate and pack a wound?

A
  1. Check doctors orders from previous packings
  2. blue pad to catch drainage, set up sterile field (ABD pad, 4x4, 2x2, syringe, cut packing dressings)
  3. clean gloves, reomve dressing and inspect
  4. face shield and new clean gloves, irrigate wound bed (top to bottom, zig zag motion
  5. Clean surrounding skin (3 times each side)
  6. 4x4 in wound bed to soak up excess saline, dry each side
  7. assess using measure, use q-tip
  8. take swab and out 1 inch in an rotate 1 cm and put in tube
  9. face shield off, sterile gloves, pack wound bed, put in normal saline and wring out, fluff don’t stuff
  10. cover with new dressing
41
Q

Dressing change with JP drain?

A
  1. Set up sterile field, clean gloves, remove outer dressing and assess, g tweezers inner dressing
  2. new clean gloves/face shield, clean incision 1st, clean close to drain in circle and work way out (3 times), dry incision/drain sit with 1 gauze for each
  3. assess incision and drain site with REEDA
  4. blue pad under drain, squeeze drain into container and don’t contaminate tip, leave suction off
  5. remove drain with sterile gloves, take 4x4 with hands and place next to site and hold with non-dom hand
  6. remove drain with dominant hand and pull out, clean after
  7. use tweezers and put on new dressing
42
Q

DC with hemovac drain?

A
  1. Sterile field, clean glove, remove dressing/assess
  2. face shield/clean gloves, clean incision, clean drain site (3 swipes with different gauze working out), dry incision/drain
  3. Inspect incision and drain using REEDA
  4. blue pad, release suction/plug, tilt drain drain into cup (assess for amount, colour)
  5. sterile gloves, gauze in one hand and other hand pull out drain
  6. apply new dressing
43
Q

Risk factors for surgery?

A

Age (young and old), nutrition, obesity, immune competence (risk for infection), fluid and electrolytes imbalance (shifts during surgery).

44
Q

Day of surgery?

A

Hygiene (patient shower before, no makeup/nail polish), removes prostheses and dentures, void before surgery/laxatives sometimes, vital signs, document, allergies, eliminate wrong site/surgery (double check process).

45
Q

What’s informed consent?

A

Explain precedence/risk and benefits/ outcomes/ recovery process/alternatives. Usually doctor does this but nurse can answer questions and be the in between person.

46
Q

General anesthesia, regional, and local?

A

General- loss of sensation, reflex, consciousness overall
Regional- loose sensation to large area of body
Local- loose sensation to small area of body like tooth filling

47
Q

What’s procedural sedation?

A

Depressed level of consciousness. Reflexes not loss like wisdom teeth removal.

48
Q

More about regional anesthesia and what if affects?

A

Affects sympathetic nerves (fight or flight) which results in vasodilation. Affects sensory nerves (decreased sensation with pain and temperature changes), and motor nerves ( e.g. can’t make legs).

49
Q

What to do post-operative procedure?

A

Given a report. Assess ABCs (airway, breathing, circulation). Assess mental status, incision site, temperature, IV fluids, pain. Priorities are ABCs, prevent wound infection, manage pain.

50
Q

What is dermatone?

A

Area of skin supplied by a spinal nerve. Use ice to assess patients skin and see if they feel its temperature. We want decreased sensation of ice in surgical area.

51
Q

What is PCA?

A

Patient controlled analgesia. Self administration of opioid analgesic. Push button to release opioid by IV. Monitored by RN and assess for comfort level, O2, RR, sedation level. Side effects are respiratory depression and naloxone used to combat adverse effects.

52
Q

What is epidural analgesia?

A

Inject anise this into epidural space. Assess for HR, RR, BP, sedation and comfort level, O2 stats, sensory level, motor function, and the epidural site.

53
Q

What is complete and incomplete fracture?

A

Complete- break through entire bone width
Incomplete- break through part of bone

54
Q

Bone healing phases?

A
  1. Hematoma- semisolid clot form 24-72 hrs
  2. Converted into Granulation tissue (fibrocartilage) 3-14 days
  3. Callus formation causes minerals to be deposited within 6 weeks
  4. Osteoblastic proliferation is callus reabsorbed, transform to bone, start 4-6 weeks and can take up to 1 yr
  5. Bone remodel- pre injury shape and strength starts at 4-6 weeks and can take up to 1 yr
55
Q

What is pathologic/fragility fracture, fatigue/stress fracture, and compression fracture?

A
  1. Occur during normal activity or following minimal injury when bone is weakened by disease process
  2. Normal bone subjected to repeated stress without bone/muscle recovery
  3. Force applied to long axis of cancellous bone
56
Q

What are complications of fractures?

A

Venous thromoembolism (VTE)-blood clot forms in vein, S+S (edema, warmth, tender), prevent by anti-embolism socks, mobility, dx by doppler ultrasound

Infection- S+S (tenderness, pain, redness, swell, purulent drainage, warmth, delayed or no union of surgical site)

Acute compartment syndrome- increase tissue pressure in limited space cause decreased perfusion, S+S (pain, pallor, paralysis, pulseness), prevent by ice/elevate, treatment remove ice

Fat embolism syndrome (FES)- fat globules released from bone marrow to bloodstream 12-48 hrs after surgery=reduced perfusion, S+S (agitation, vision change, headache. LOC)

57
Q

What is etiology, incidence, and health promotion of fractures?

A

E- trauma, sports, malnutrition, bone disease
I- rib, femur, wrist fractures
HP- health teaching on risks for musculoskeletal injury

58
Q

Neurovasuclar assessment?

A

CMS (circulation-colour, temp., cap refill, pulse, movement, sensation-pain)

59
Q

Physical assessment for fractures?

A

Edema, pain, muscle spasm, deformity, ecchymosis, loss of function, crepitation.

60
Q

Non-surgical management of fracture?

A

Closed reduction (manual realignment of bone fragments to previous position), splints/boots/casts (immobilization), traction (apply pulling forces to injured part of body while counter traction pulls in opposite direction).

61
Q

Cast care?

A

Post cast elevate limb, apply ice, avoid handling, neurovascular check (CMS), and don’t get wet.

62
Q

What are intracapsular and extra capsular hip fractures?

A

I- femoral neck fractures, inside joint capsule, usually r/t bone disease, treat with insertion of femoral head prethesitc
E- outside of joint capsule, usually r/t fall or trauma, treat with screws/pins

63
Q

What is total hip atrthrolasty?

A

Replacement of total hip. Sever trauma was caused. Prosthetic ball and socket.

Nursing 220 (10 decks)

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