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
