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201 sterile glove technique Flashcards

1
Q

what cream is used for mild to moderate Incontinence associated dermatitis?

A

-basic protectant silicone 24%
-remedy hydraguard cream

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2
Q

what is the cream used for moderate to severe IAD?

A

-advanced protect zinc 30%
-secura extra protective

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3
Q

what cream is the txt for dry, cracked skin?

A

-advanced moisturizer urea 10% aha 4%
-attrac-tain cream

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4
Q

what is used prevention and txt of interigo (red, itchy, burning skin fold)

A

-skin fold textile silver
-interdry ag sheet

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5
Q

what is the goal of surgical drains for simple wounds?

A

to decompress or drain either fluid or air from the area of surgery

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6
Q

what are the types and subcategories of surgical drains?

A

-closed drainage system : jackson-pratt, hemovac drain
-open drainage: penrose
-other: wound drainage bag (ostomy bag with a drain) which may be used for chronic wound with lots of drainage , and percutanous drain secured with a stat-lock

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7
Q

what is a hemovac and what does it do?

A

-also called a 400 ml drain (total volume is 400ml/24 hours): usually emptied when half full or per facility policy
-it is a portable self-contained unit
-it is placed into a vascular space where blood drainage is expected after surgery (such as with abdominal and orthopaedic surgery)
-suction is maintained by compressing a spring like device

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8
Q

what is a jackson pratt drain and what does it do?

A

-also called a 100ml drain (100ml/24 hours): usually emptied when 25-50 ml or per policy
-it is a portable self contained unit
-shaped like a bulb
-consists of a perforated round or flat tube connected to a negative collection device

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9
Q

what is a penrose drain?

A

-an open drainage system
-is made out of soft rubber tube
-no sunction
-held in place with a safety pin
-usually pulled out in stages (using sterile technique and sterile safety pin)

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10
Q

what are wound drainage bags used for?

A

used for wounds that have lots of drainage

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11
Q

what is a percutaneous drain and what is it used for?

A

-it is a small plastic drain through the skin that is attached to a drainage bag
-used to drain an abscess
-may use a securement device
-often covered with a clear transparent dressing
-requires weekly dressing changes and prn

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12
Q

how do you empty a drain?

A

-clean gloves
-release vacuum by opening the drain port
-empty drainage into appropriate container
-to re-establish suction: place the container on a flat surface, and have the palm of one hand hold down the top and bottom together, and the other hand clean the port (make sure to close the port before releasing the hold)

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13
Q

what are some things you should know about a pts’ drain?

A

-what it’s used for and how long it should be in
-if the surgeon wants the drain to be wet or not

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14
Q

what situations should a client not get the drain wet?

A

-if the drain is in-situ short term
-pts with penrose drain should not shower until the drain is out
-a client with hemovac or JP that is expected to be removed in 3-4 days once the drainage has slowed down may not need to shower

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15
Q

what situations can the client get their drain wet?

A

-long term g tubes (feeding tubes)
-if client showers, the dressing should be kept dry

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16
Q

what can cause pressure ulcers?

A

-localized ischemia (deficiency of blood supply to the tissue)
-lower limb injury (increased risk of developing a pressure injury to the heal)
-incorrect use of therapeutic support surfaces
-declining condition: when there’s a change in client’s condition make sure to repeat braden scale assessment to decrease risk, then implementing pressure injury strategies based on changes in the braden scale assessment can prevent pressure injuries

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17
Q

location, how deep, drainage with pressure ulcers?

A

-over bony prominences
-can be shallow or deep, and go through to bone
-wound base may be covered with slough or eschar
-no drainage to large amounts of serous or purulent depending on the stage

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18
Q

what is the braden scale flow important for?

A

prevention of wound injuries

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19
Q

when would you complete the braden risk and skin assessment?

A

-within 8 hours of admission
-upon return from the OR
-if pt is at risk: every shift
-it pt is not at risk: at least daily

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20
Q

if a wound gets better, do you down stage it?

A

No, because tissue that was lost in the original wound was not replaced - granulation tissue fills the defect

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21
Q

what is stage 1 pressure injury?

A

-intact skin with non-blanchable redness of a localized area, usually over a bony prominence
-darkly pigmented skin may not have visible blanching
-color may be different from the surrounding area

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22
Q

what is stage 2 pressure ulcer?

A

-partial thickness loss of dermis
-presents as a shallow open ulcer with a red pink wound bed, without slough
-can also present as an intact of open/ruptured serum filled or serosanguineous filled blister

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23
Q

what is stage 3 pressure ulcer?

A

-full thickness skin loss which subcutaneous tissue is visible
-granulation tissue is often present
-may extend down, but not through fascia

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24
Q

what is a stage 4 pressure ulcer?

A

-full thickness skin loss with extensive damage or tissue necrosis to muscle, bone or supporting structures (tendon, joint capsule)
-slough, eschar or both may be visble
-rolled edges, underminng, tunnelling or a combination often occur

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25
Q

what is unstageable pressure ulcer?

A

-full thickness skin and tissue loss
-unable to determine extend of damage/depth of the wound due to presence of slough or eschar

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26
Q

what is deep tissue injury?

A

-non-blanchable intact/ non-intact skin
-deep red, purple or maroon discolouration (may appear differently in darkly pigmented skin)
-may reveal a dark wound or blood filled blister
-painful, firm or mushy
-may get worse and expose severity of the injury or it may improve and heal w/o causing futhur damage

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27
Q

what are tips for assessing darkly pigmented skin?

A

-be more highly suspicious of pressure injuries (early visible signs are delayed by the pigment by sometimes up to 48 h)
-good lightening
-compare the colour of the wound skin and periwound
-use a chart to describe variations
-moisten the skin (darker skin is usually thicker and drier)
-palpate the skin that has been exposed to pressure and shear
-be aware of different presentations of DTPI
-consider using technology to assess perfusion and subepidermal moisture (infrared thermography)
-superficial wounds are easily more identified and open blisters usually still have the epidermis
-healing wounds can lead to changes in pigmentation: inflammatory = skin may turn tan, brown, purple, healing = hypopigmentation

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28
Q

how can you prevent pressure injuries?

A

-promote activity/mobility
-encourage good nutrition and appropriate hydration
-prevent/manage moisture assosciated skin damage
-skin integrity assessment including bony prominences (atleast once a day)
-complete risk assesment tool as required ( less than 18 means at risk)
-keep HOB less than 30 degrees when possible
-provide skin care
-treat any skin wounds or tears promptly
-frequent turning and positioning
-off loading heal pressure
-providing pressure reducing support surfce
-use foam wedges for side lying

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29
Q

what is a treatment for stage 1 pressure ulcer?

A

-relieve pressure
-protect (barrier pressure)
-prevent from becoming worse

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30
Q

what is the txt for stage 2?

A

-relieve pressure
-usually there’s no dressing (but there’s barrier cream), but sometimes a dressing is on the wound to absorb drainage
-debride slough if present
-protect

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31
Q

what is the txt of stage 3 or 4?

A

-relieve pressure
-debride slough/eschar if present
-pack deep wounds and sinus tracts/undermining if present
-dressing to absorb drainage
-decrease bacterial colonization
-protect

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32
Q

what is the txt of unstageable pressure ulcer?

A

-surgical debridement to remove eschar
-if non-surgical, keep dry, protect, and prevent infection (maintenance wound)
-products used: iodine swab or liquid with cotton swab, iodasorb ointment (good for diabetic ulcers), inadine (antimicrobial providone impregnanted gauze)

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33
Q

what is the txt of deep tissue injury?

A

-depends on presentation and when/if the wound becomes open
-may become stage 3 or 4
-some txt: air-fluidized therapy (causes finely divied particles to acquire the characteristics of fluid), and non-contact low frequency ultrasound therapy (low energy ultrasound generated mist used to promote wound healing)

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34
Q

what is a venous ulcer?

A

-shallow, superficial, irregular shape ulcer
-usually appear distal medial 1/3 of the lower leg and ankle
-peri wound is often edematous with weeping dermatitis (swollen,red skin), occasional cellulitis
-skin color may be cyanotic, reddish-brown, or red due to dermatitis
-moderate to large serous draining
-peripheral pulses are palpable (may be difficult to find due to edema), cap refill normal
-aching pain when legs dependent (when legs are hanging down or same level as the heart): relieved on elevation
-81% of ulcers are venous

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35
Q

what are venous ulcers caused by?

A

chronic venous insufficiency and the associated ambulatory venous hypertension

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36
Q

what is the txt for venous ulcers?

A

-cleanse, irrigate prn
-use autolytic debridment if indicated
-absorbent dressing to maintain moisture balance but keep peri wound skin dry
-elevate legs above heart to minimize edema, improve circulation, decrease pain
-compression stockings if not contraindicated
analgesic prn

37
Q

when is compression therapy used?

A

-in conjunction with wound txt for venous ulcers from venous insuffiency
-client education
-if stockings are worn every day, they need to be replaced every 6 months

38
Q

what is arterial ulcer caused by?

A

severe tissue ischemia

39
Q

what is an arterial ulcer?

A

-“punched out” appearance and round
-shallow or deep, pale pink or yellow base, necrotic and eschar common
-commonly on the toes, metatarsal heads, lateral malleolus, heels
-little or no drainage
-peri wound skin thin, dry, shiny with hair loss on lower extremities, thickened toenails and callouses
-often severe pain: relieved by lowering the leg below heart level (eg. dangling leg over the edge of the bed)
-peripheral pulses dimished or absent, cap refill delayed
-ABI = Ankle brachial index (measures blood flow in the legs compared to the arms) less than 0.91 (normal 1.0-1.4)
-skin temp cool/cold
-color pale on elevation and rubour when dependent (arm or leg is hanging lower than the heart
-pain often sever: worse with activity or elevation

40
Q

what is the txt for healable, arterial ulcers

A

-for dry ulcers: keep dry, maintain eschar dry, use antiseptic and dry dressing as needed
-for wet ulcers: support moist wound healing, use autolytic debridement if indicated

41
Q

what is the txt for non-healable, arterial ulcers?

A

-for dry ulcers, keep dry, maintain dry eschar, use antiseptic and dry dressing prn
-for wet ulcers, dry and protect the wound with antiseptic and dry dressing
-do not debride wet or dry wounds if non-healable

42
Q

what are others ways of txt for arterial ulcers?

A

-pain management, analgesic prn
-positioning for comfort
-good foot care

43
Q

what are diabetic ulcers?

A

-shallow or deep, may probe to bone (meaning the infection has reached the bone)
-may be necrotic, pink or pale
-usually at presssure points on the plantar suface
-small to moderate drainage: dry or wet gangrene may be present
-callouses are common to peri-wound skin
-usually painless
-peripheral pulses are palpable
-change in sensation

44
Q

what is the txt for diabetic ulcers?

A

-cleanse, irrigate
-use autolytic debridement if indicated
-maintain moisture balance
-keep peri wound skin dry
-protect wound
-analgesics prn
-monitor and control blood sugars
-regular feet inspection; appropriate foot and nail care

45
Q

what are factors that affect wound healing?

A

-wound temperature (saline cools the wound, but first the wound has to reach body temp to start healing)
-frequency of dressing changes (cooling effect)
-moisture (too wet/dry)
-yellow slough or necrotic tissue inhibiting granulation tissue (debride)
-packed too tight (damages tissues)
-dead space not filled (the open may close prematurely)
-infection (wound will not heal until resolved)
-pressure on wound (can damage tissue/prevent healing)

46
Q

what are the principle of wound care?

A
  1. assess and treat the underlying cause
  2. debride necrotic tissue
  3. maintain a moist environment
    4.assess and protect peri-wound skin
    5.promote and support granulation tissue
  4. fill dead space
  5. stop infection and trauam
47
Q

what are factors to consider about a person’s underlying cause?

A

-nutritional status
-chronic helath conditons
-equipment: wheelchair, mattress (pressure)
-underlying infection

48
Q

what are types of debridement?

A

-autolytic (eg. gels)
-enzymatic (use of an enzyme)
-mechanical (physical force loosens/removes dead tissue) : irrigation, shower, whirlpool, dressing removal
-surgical/sharp ( only ET nurses or physicians)
-natural (eg. maggots, leeches)

49
Q

what is natural debridement?

A

-maggots eating necrotic tissue
-maggots secrete calcium carbonate and ammonia which disinfect wounds
-provide warmth with may stimulate tissue growth
-increase fibroblast which promotes granulation tissue

50
Q

when do you remove maggot gauze on the skin?

A

in 2-3 days

51
Q

what is another natural therapy besides maggots?

A

-leeches: have unique saliva that increases blood flow, and contains anticoagulant properties that prevent clotting
-once the maggots are full of blood, they detach from the body

52
Q

when would you use leech therapy?

A

-to reduce severe and dangerous venous engoregement (swelling) post surgery in fingers, toes, ears and scalp reattachments
-limp transplants
-skin flap surgery
-breast reconstruction

53
Q

why would you maintain a moist environment?

A

-to promote angiogenesis (blood vessel development), tissue growth, and cell migration

54
Q

if a wound is too dry or too wet what do you do?

A

-dry: apply a produc to add moisture
-wet: apply a product to absorb moisture
-if the dressing becomes saturated, change the dressing

55
Q

what are you assessing for, on the peri wound?

A

-assess for maceration , if there is, you might need a more absorbent dressing or increase the frequency of dressing change
-assess for redness, irritation, or skin breakdown: may be the surrounding skin needs a barrier

56
Q

how can you promote and support granulation tissue?

A

-encourage good nutrition
-avoid frequent dressing changes
-cleanse with each wound change
-be gentle when cleansing fragile tissue
-use non adherent dressing if dressing is sticking

57
Q

why would you want to fill up the dead space?

A

-to allow the wounds to heal from the bottom up
-use loose “fluffy” packing material to fill in the open wounds (fluff don’t stuff)
-damp packing not wet
-fill areas of undermining and sinus
-use one piece of gauze/packing if possible (or ensure all pieces can be removed easily and not accidentally left in the wound)

58
Q

do wounds normally contain bacteria?

A

yes

59
Q

what is bacteria colonization?

A

-bacterial attached to the wound bed starts replicating, but may not be infected
-treat with iodine

60
Q

whats an infection?

A

-when the wound becomes infected and the bacteria starts to invade the surrounding tissues causing an inflammatory response which can lead to a local infection and maybe a systemic infection
-treat with iodine and antibiotics

61
Q

how can you help with the diagnose and treatment of an infection?

A

-culture and sensitivity
-systemic antibiotics
-wick draining to prevent abscess formation if warranted
-change dressing more frequently to remove contaminated drainage
-observe closely for deterioration (locally and systemically)

62
Q

what will nurse do if they suspect a wound infection?

A

-if there are 2+ s/s of local or systemic wound infection, the nurse will obtain a C & S swab
-the assessment is what diagnoses the infection, not the culture results
-may start oral or IV antibiotics (may be ordered before or after culture results come back)
-will need to use a anti-microbial wound care products to decrease bacteria in the wound

63
Q

how do you obtain a C & S swab?

A

-cleanse wound with 60-100 ml of saline
-swab only granulation tissue (not eschar, slough, pus or exudate)
-rotate swab over 1 cm square area of wound for 5 seconds (may need to press into the wound to obtain fluid)
-label specimen with client ID, swab source site, current antibiotic therapy and any pertinent info (eg. diagnosis, suspected causative agent)
-refrigerate swab and transport lab within 12 hours in biohazard bag

64
Q

how can you protect a wound?

A

-protective dressing
-removing dressing and tape appropriately
-off loading
-use non adherent dressing when necessary

65
Q

what are wound care txts?

A

-pack sinus tracts and cavities
-provide moisture
-prevent sticking of dressing
-absorb excess exudate
-promote autolysis of necrotic tissue
-pad and insult to prevent trauma
-prevent bacterial invasion/decrease bacterial colonization
-debride (clean, remove packing and hydrofiber)

66
Q

when should a wound dressing be changed?

A

-too wet/leaking drainage
-too dry
-ordered (eg. VAC changed 3x/week or per policy)
-when product has reached time limit (eg 7 days)
-when loose or falling off
-for chronic wounds, if wound dressing appropriate and no issues then q 3-5 days the dressing is changed

67
Q

when cleaning a surgical incision, what direction do you go to?

A

from clean to dirty using a clean swab every time

68
Q

when cleaning an open surgical incision what direction do you clean?

A

-clean to dirty
-if a surgical drain site, clean to dirty (meaning from drain site outwards), using a clean swab each time

69
Q

if there is an incision and a drain site, which one do you clean first?

A

cleanse the incision (clean) and then the drain site (dirty)

70
Q

can a pt with a chronic would shower?

A

yes, showering may assist a dressing to loosen from the wound bed with less mechanical trauma than removing a dressing that is dry

71
Q

what patient teaching be done regarding wound care?

A

-s/s of infection and when to call the doctor or go into a clinic
-healing time
-importance of good nutrition (protein, vit c & b & d, iron, zinc, calories)
-importance of fluids (2500 + ml/day)
-hygiene (preventing infection/sepsis): hand hygiene before and after dressing changes, clean area for storage of dressings)
-positioning and off loading
-proper disposal of dressing
-how the client may bathe/shower with the wound
-portable tap water may be used to clean the wounds

72
Q

where would you document for closed incisons & minor superficial wounds, drains, suture/staple removal, open wounds?

A

-closed incisions & minor superficial wounds: 24 h record, narrative notes prn
-drains: 24 h record, narrative notes, in/out
-suture/staple removal: 24 h record, narrative notes
-open wounds: wound assessment and treatment flow sheet (put a checkmark ont eh 24 h record), and narrative notes if concerns

73
Q

when is a wound assessment and treatment flowsheet (WATFS) initated

A

when there is wound present

74
Q

when is a WAFTS filled out?

A

each time a dressing change is scheduled to be changed

75
Q

when is a full assessment using WAFTS done?

A

every week (7 days) and whenever a significant change occurs (eg. odour develops, wound deteriorates)

76
Q

when is a partial wound assessment done?

A

for dressing changes that occur between weekly assessments (this includes all assessment parameters except measuring the wound)

77
Q

when the wound is closed and no longer requires care, what do you write on the WAFTS?

A

“closed” on the assessment form and the entry initialled

78
Q

what are the 3 types of goals of care on the WATFS?

A

-to heal
-to maintain (preventing it from getting worse)
-to monitor/manage (cancer wound

79
Q

when would you need to fill out a PSLS for wound care?

A

if it’s a skin tear, pressure injury, incontinence

80
Q

when would you measure the size of the wound?

A

every week or if there’s a change in the wound

81
Q

what is the measurement of wound?

A

cms

82
Q

what are sinus tracts and how do you measure them?

A

-visible tunnels that can extend deep into the tissues
-measure each sinus
-location is recorded in “o clock”, using a 12 hour clock (towards the head is 12 and towards the feet is 6)
-use a sterile 1 tip and paper measuring tape, or a measuring too,

83
Q

what is undermining and how do you measure?

A

-hidden missing pieces of skin that are under overhanging skin
-location uses o clock
-use sterile Q tip, paper measuring tape or measurement tool

84
Q

how do you describe exudate?

A

-by the % of each color of exudate present
-all percentages must add up to 100

85
Q

what are the exudate categories?

A

-none
-scant/small
-moderate: half of dressing is saturated with drainage
-large/copious: entire dressing saturated

86
Q

when do you assess for odour?

A

after cleansing the wound

87
Q

what is demarcated and diffused wound edges?

A

-demarcated: edges are clearly seen
-diffuse: edges not clearly see

88
Q

what is indurated, excoriated, callused peri sound skin?

A

-indurated: abnormal firmness around the wound
-excoriated: superficial loss of tissue
-callused: thicked layer of the epidermis

89
Q

what kind of pressure ulcer requires packing?

A

-stage 4
-pack any wound greater than 1 cm

finals (12 decks)

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