183 Unit 2 Flashcards
Asepsis
Includes all activities to prevent infection or break the chain of infection. The nurse uses septic technique to half the spread of microorganisms and minimize the threat of infection. There are two asepsis categories: medical asepsis and surgical asepsis.
Medical asepsis
Aka clean technique, involve procedures and practice that reduce the number and transfer of pathogens. Medical asepsis procedure include performing hand hygiene and wearing gloves.
Surgical asepsis
aka sterile technique, includes practice used to render and keep object and area free from microorganisms. Surgical asepsis procedure include inserting an indwellonf urinary catheter or inserting an IV catheter.
10 principle of surgical a sepsis
- All objects used in a sterile field must be sterile. 2. A sterile object become non-sterile when touched by a non-sterile object. 3. Sterile items that are below the waist level, are considered to be non-sterile. 4. Sterile fields must always be kept in sight to be considered sterile. 5. When opening sterile equipment and adding supplies to a sterile field, take care to avoid contamination. 6.any puncture, moisture, or tear that passes through a sterile barrier must be consider contaminated. 7. Once a sterile field is set up, the border of one inch at the edge of the sterile drape is considered non-sterile. 8. If there is any doubt about the sterility of an object, it is consider non-sterile. 9. Sterile persons or sterile objects may only contact sterile areas; non-sterile persons or items contact only non-sterile areas. 10. Movement around and in the sterile field must not compromise or contaminate the sterile field.
Wound
Is a break or disruption in the normal integrity of the skin and tissues. Wounds may result from mechanical forces( surgical incision) or physical injury (burn).
intentional wound
The result of planned invasive therapy or treatment. Example include those that result from surgery, intravenous therapy, and lumbar puncture. Risk for infection is decreased, and healing is facilitated.
Unintentional wound
Accidental, high risk for infection and a longer healing time.
Open wound
Occur from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Increases risk for infection and delayed healing accompany open wounds. Example include incision and abrasion.
Closed wound
Result from a blow, force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash. Example include ecchymosis and hematomas.
Acute wound
Surgical incision, usually heal within days to weeks. Risk of infection is less.
Chronic wound
Does not progress through the normal sequence of repair. The healing process is impeded. Risk of infection is increases healing delayed. Remain in the inflammatory phase of healing. Chronic are any wound that does not heal along the expected continuum.
Wound healing
Process of tissue response to injury.
Incision
Cutting or sharp instrument; wound edges in close approximation and aligned.
Contusion
Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma
Abrasion
Friction; rubbing or scraping epidermal layers of skins; top layer of skin abraded.
Lacerations
Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned often with loose flaps of skin and tissue
Puncture
Blunt or sharp instrument puncturing the skin intentional or accidental
Penetrating
Foreign object entering the skin or mucous membranes and lodging in underlying tissue fragment possibly scattering throughout tissues.
Avulsion
Tearing a structure from normal anatomic position, possible damage to blood vessels, nerves, and other structure.
Chemical
Toxic agent such as drugs, acids, alcohol, metal, and substance released from cellular necrosis.
Thermal
High or low temperature cellular necrosis as a possible result
Irradiation
Ultraviolet light or radiation exposure
Pressure ulcer
Compromised circulation secondary to pressure or pressure combined with friction
Venous ulcers
Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction.
Arterial ulcers
Injury and underlying ischemia resulting from underlying condition such as atherosclerosis or thrombosis
Diabetic ulcers
Injury and underlying diabetic neuropathy peripheral arterial disease diabetic foot structure
Wound repair stages
Primary intention, secondary intention, tertiary intention.
Primary intention
Wounds healed by primary intention are well approximated. Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges usually healed by primary intention. Primary become infected, it will heal by secondary.
Secondary intention
Edges that are not well approximated. Large open wound such as from burns or major trauma which require more tissue replacement and are often contaminated commonly healed by secondary
Tertiary intention
Delayed primary closures, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain and then are closed
Phases of wound healing
Hemostasis, inflammatory phase, proliferation phase and maturation phase
Hemostasis phase
Occurs immediately after the initial injury involves blood vessels constrict and blood clotting begins through plateau activation and clustering.
Inflammatory phase
The inflammatory follow hemostasis and last about 4 to 6 days. White blood cells, predominantly leukocyte and macrophages move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hr after the injury macrophages enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They release growth factor that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblast that help to fill in the wound, which is necessary for the next stage of healing. Acute inflammatory is characterized by pain, heat, redness, and swelling at the site of injury. During the inflammatory phase, the patient had a generalized body response, including a mildly elevated temp, leukocytosis, and generalized malaise.
Proliferation phase
Known as the fibrolastic, regenerative, or connective tissue phase. Last for several weeks. New tissue is built to fill the wound, primarily through the action of fibroblast. Fibroblast are connective tissue cell that synthesize and secrete collagen and produce specialize growth factors Responsible for inducing blood vessel formation as well as increasing the number in movement of endothelial cells.Phase featured three distinct stages one Filling the wound stage two contaction of the wound margin stage three covering the wound ( epithelization). During the first stage shiny deep red granulation tissue fills the word bed with connective tissue and new blood vessel are formed. During contraction the wound margin contract and pull toward the center of the woundIn the third stage Epithelial cells arise from the wound bed or margin and begin to migrate across the wound bed until the wound is cover with epithelium.
Maturation phase
New tissue slowly gain strength and flexibility. Collagen fibers re-organize the tissue remodels and mature and there is an overall increase in tensile strength(80% of pre injury) .The maturation Fais varies greatly from wound to wound, Often lasting anywhere from 21 days to years.
Granulation tissue
Then layer of Epithelial cells form across the wound is reinstated
Desiccation
Dehydration. Cells dehydrated and die in cry environments. Wounds that are kept moist and hydrated expiernexe enhanced epidermal cell migration, which support epitheliazation( epithelial cell migration to the wound)
Maceration
Over hydration.
Necrosis
Death of tissue
Biofilm
A thick grouping of microorganisms
Wound complications
infection, hemorrhage, dehiscence, evisceration, and fistula.
Infection
Wound infection results when the patient immune system fails to control the growth of microorganisms. Symptoms of infection include purulent drainage, increased drainage, pain, redness, and swelling in and around the wound; increased body temp and increased white blood cell.
Hemorrhage
Hemorrhage me occurs from a slip sutures, a dislodge the clot I am the wound site, infection, or the erosion of a blood vessel by a foreign body such as a drain. Check wound frequently during first 48 hours after the injury and no less than every eight hours.
Dehiscence
The partial or total separation of woman layers as a result of excessive stress on one that is not heal. An increase in the flow of fluids from the war between post operative days four and five may be a sign of an impending dehiscence.
Evisceration
The more serious complication of dehiscence. The wound completely separates, with protrusion of viscera through the incisional area. Greater risk forPatient that are obese malnourished smoke tobacco use anticoagulant I have infected wounds or experience excessive coughing and vomiting or straining.
Exudate
Fluid that accumulates in a reward may contain serum cellular debris bacteria and white blood cells
Serous drainage
Composed primarily of the clear serous Portion of the blood and from serous Membranes. Serous Drainage is clear and watery.
Sanguineous drainage
Chances of large numbers of red blood cells and looks like blood. Bright red sanguinous drainage Is indicative of fresh bleeding, where as darker drainage indicate older bleeding.
Serosanguineous drainage
Is a mixture of serum and red blood cells. It is light pink to blood tinged.
Purulent drainage
Made up of white blood cells, liquefy dead tissue debris, and both dead and live bacteria. Purulent Drainage is sick, often has a musty or foul odor, and varies in color, depending on the causative organism.
Common types of drains
Penrose, t-tube, Jackson-Pratt, hemovac, gauze-iodoform gauze-nugauze. Assess the amount color order and consistency of the wound drainage. ( coca )
Penrose
Purpose - provide sinus tract. Ex. After incision and drainage of abscess, in abdominal surgery.
T-tube
Purpose - for bile drainage. Ex. After gallbladder surgery.
Jackson-Pratt
Purpose - decrease dead space by collecting drainage. Ex - after breast removal, abdominal surgery.
Hemovac
Purpose - decrease dead space by collecting drainage. Ex. After abdominal, orthopedic surgery.
Gauze - iodoform gauze - NuGauze
Purpose - allow healing from base of wound. Ex - infected wounds, after removal of hemorrhoids.
An ideal dressing
Maintain a moist environment, be absorbing, provide thermal insulation, act as a bacterial barrier, reduce or illuminate pain Wound site, and allow for Pain free removal.
Dressing purpose
Divide physical, psychological, and aesthetic comfort. Prevent, eliminate, or control infection. Absorb drainage. Maintain a moist wound environment. Protect the wound from further injury. Protect the skin surrounding the wound. Remove necrotic tissue.
Debridement
Removal of devitalized tissue and foreign material
Types of tape
Adhesive, paper, plastic, acetate, micro foam
Adhesive tape
Used for Strength, support, and economy. To secure dressing and splint. To strip joints to prevent Athletic injuries. To immobilize or stabilize body parts. To provide pressure. To approximate wound edges.
Paper, plastic, acetate tape
Increase comfort, decrease allergic and skin problems. To close small wounds.To secure dressings.
Microfoam tape
Use for compression or pressure dressing
Types of binders
Slings - arms , Abdominal binders, chest binders, t- binders ( hold dressing groin area ), straight binder - chest and the abdomen. Montgomery straps use Ties attached to an a piece of backing to hold dressing in place, Use in preventing skin irritation and damage due to constant re-taping with dressing changes.
Heat and cold therapy
Heat accelerate the Inflammatory response to promote healing. The local application of court constrict pperipheral Blood vessels, reduce muscle spasm, and promote comfort.
Heat
Dilates peripheral blood vessel, increase tissue metabolism, reduce blood viscosity and increased capillary permeability, reduces Muscle tension, and help relieve pain. Vasodilation increases local blood flow and turn the supply of oxygen and nutrients to the area is increase. Increase tissue metabolism, accelerate the inflammatory response to promote healing. Reduces muscle tension to promote relaxation and help to relieve muscle spasm and joint stiffness. Relieve pain by stimulating specific nerves fiber, closing the gate allow the transmission of pain stimuli to center in the brain. He used to treat infections, surgical wounds, inflamed tissue, arthritis, joint and muscle pain, dysmenorrhea, and chronic pain. Systemic effect of prolonged heat include Increase cardiac output, Swelling, increased pulse rate, and decreased blood pressure. Increase blood flow to an area while decreasing it to another can cause hypovolemic shock
Cold
Constrict peripheral blood vessel, reduce muscle spasm, promote comfort. Called reduced blood flow to tissue and decrease the local release of pain producing substance such as histamine, serotonin, and bradykinin. This action and turns reduce the formation of Adema and inflammation. Decreased metabolic needs and capillary permeability, combined with increased coagulation in blood at the wound site, Priscilla Tate to control bleeding and reduce edema formation. Exposure to prolong or extensive cold environment can increase blood pressure, shivering, and goosebumps.
Physiologic consideration of heat and cold
Produce maximum vasodilation in 20 to 30 minutes if heat is continue beyond that time tissue congestion and vasoconstriction occurs. With cold, maximum basal constriction occurs when the skin reaches 60f or 15c then vasodilation occur. Receptor adapt to temp rapidly then slowly. Increasing the temperature with the lengthening the time of application can damage tissue.
Dry heat
Hot water bags ( easy and inexpensive), Electric heating pad ( used anterior ly and laterally not under the patient ), aquathermia pad ( can be place under patient Back pain, muscle spasms, Mild information, and thrombophlebitis), and hot pack
Moist heat
Warm moist compresses ( promote circulation And healing and to reduce edema - moist heat evaporate and cool rapidly make sure to frequently change and or cover with beating agent such as aqua -k pad). Sitz bath Or a method of applying tepid or warm Water to the pelvic, Perineal, Or rectal area by sitting in a tub, special chair, or basin. Warm soaks Increase blood supply to a local infected area, Aid In cleaning large, sloughing wounds, Improve circulation, and to apply medication to a local Ly infected area.If a song is proscribed for a large woundExpect to adapt a sterile technique tap water maybe use Because it is excepted as being free from pathogens. Unless the temperature is prescribed set water 105 to 109 treatment usually takes 15 to 20 minute.
Dry cold
Ice bag ( easy and inexpensive ) apply 30 remove for 1 hr repeat. Cold pack.
Moist cold
Cold compresses ( might be used for Eye, Headaches, tooth extraction, hemorrhoids - basically wet towels)
Slough
A layer or mass of dead tissue separated from surrounding living tissue.
Reactive hyperemia
Body flooding of an area with blood after it has suffered from poor circulation for a. The occurrence of a blanchable Redding of the skin when pressure is removed. Cap refill
Ischemia
Deficiency of blood in a particular area
Debrided - debridement
Cleaning away antibiotics tissue and foreign matters from wound
Eschar
A thick leathery scab dry cross that is necrotic and must be removed for adequate healing to occur
Purulent
Containing pus
Exudate
Fluids that accumulate In a wround, May contain serum, cellular debris, bacteria, and white blood cell
Evisceration
Protrusion of viscera through an incision
Stage 1 or superficial dermal ulcer( redness, skin intact )
Intervention - Change positions frequently. Keep the bed wrinkle free and dry. If you special mattress. Reduce friction. Massage gently. No covering applied. Purpose - interventions can reverse
Superficial wounds caused by sharing or friction
Interventions - transparent dressing. Purpose - Protect from shearing, friction, contamination, allow exchange. ( tedaderm, opsite)
Superficial wound with minimal exudate
Intervention- cleanse and apply DSD ( dry sterile dressing ). Extra thick hydro colloid dressing, duoderm, sorbisan. Change if leaking or signs of infection. Purpose - Maintain a sepsis. Provides absorption of exudate. Faciliatw healing in moist environment
Wounds with loss of dermis with moderate to heavy exudate
Intervention - cleanse with normals saline. Apply hydrocollidal dressing. Duoderm control gel, intrasite. Purpose - maintains asepsis. Provide absorption of exudate. Facilitate healing in moist environment.
Wounds with a surgical drain
Intervention - change dressing frequenters. Clean and dry skin surface around drain. Protect skin with 4x4. Purpose - prevent skin from becoming excoriated.
Wounds with eschar
Apply continuous moist dressing. Purpose - removal or eschar promotes healing
Wounds with neroctoc tissue
Intervention - change moist or wet to dry dressing frequently m. Cleanse with sterile solution. Debridement with enzyme ointments applies to ulcerated area only or debridement surgically. Purpose - debridmenr removes necrotic tissue. Liquefies necrotic tissue.
Wounds with tissue loss
Intervention - use wound filler in wound only. Duoderm granules, envisages paste. Cover with colloid dressing / pack wound with saline dressing. Mesalt / use molded cavity wound dressing. Allevyn. Purpose - provide moist healing environment and remove exudate
Wound with increasing sanguineous drainage
Reinforce by adding sterile 4x4. Trace outline of drainage on dressing and write time. Recheck 30-60min. Purpose - maintains asepsis. Assess complication.
Wound assessment checklist
Location, size ( length, width, depth) , stage, drainage ( color, odor, amount ) tunneling, character of wound( slough, presence of granulation tissue etc) dressing ( what is used ) pressure relieving device.
