220 Midterm Flashcards
Medical Asepsis
“Clean Technique”
Reduce & prevent the spread of microorganisms
Use standard precautions
Surgical Asepsis
“Sterile Technique”
Procedures to eliminate all microorganisms
Any sterile object or area is considered contaminated when touched by any object that is not sterile
Principles of Surgical Asepsis
- Sterile object remains sterile only when touched by another sterile object
- Only sterile objects may be placed on a sterile field
- A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated
- A sterile object or field becomes contaminated by prolonged exposure to air
- When a sterile surface comes in contact with a wet contaminated surface, the sterile object or field becomes contaminated by capillary action
- Fluid flows in the direction of gravity
- The edges of the sterile filed or container are considered to be contaminated
Layers of the Skin
- Epidermis - dead, 0.5-1.0mm
- Dermis - vascular, 1.0-4.0mm
- Subcutaneous (hypodermis) - provides insulation
Acute Wound
A wound that heals in a timely manner (2-8 weeks)
Causes: trauma, surgical incision
Chronic Wound
Wound that fails to heal in a timely manner (over 8 weeks)
Causes: vascular compromise, chronic inflammation, repetitive insults to the tissue
Simple Wounds
Straight and in tact
not swollen, red or bruised
Little to no drainage
To change - clean gloves, sterile instruments
Complex Wounds
Not held together, not clean
Puss/drainage
To change - sterile gloves, sterile instruments
Primary Intention
VERY minor
very fine scar, about 3-7 days to fully heal
Secondary Intention
Longer repair
More scarring
Increased risk of infection
ex. burn, pressure ulcer
Tertiary Intention
Delayed closure until the risk of infection is gone
Stages of Wound Healing
- Hemostasis
- Inflammatory
- Proliferative
- Maturation
Hemostasis
Occurs within minutes of initial injury
Body sends platelets to the site of injury to aggregate and vasoconstrict blood vessels
Starts clotting cascade at the same time to stabilize the clot
Inflammatory Phase
Body’s protective response to injury
Lasts 2-4 days
Histamine released causing vasodilation and WBCs migration (Swelling)
Leukocytes and macrophages inject bacteria, dead cells and debris
Proliferative Phase
Lasts 3-24 days
New blood vessels form (O2 and nutrients)
Collagen starts to contract, decreasing wound bed size and speeds healing
Epidermal cells migrate over the granulation tissue (epithelialization)
Maturation/Remodelling
Up to 2 years
Surface of wound may look healed
Collagen production continues, thickening the epithelium and contracting to form a scar
Scar tensile strength increases to 80% of original tissue, but elasticity is limited.
Factors that Affect Wound Healing
Lifespan
Nutrition
Lifestyle
Medications
Contamination, colonization and infection
Serous
Clear, watery plasma
Purulent
Thick, yellow/green, tan or brown
Serosanguinous
Pale, red, watery - mixture of clear and red fluid
Sanguinous
Bright red - indicates active bleeding
Amounts of Drainage
Scant: <5%
Small: 5-25%
Moderate: 25-50%
Large: 50-75%
Saturated: >75%
Basic Wound Cleansing
Clean from least to most contaminated (inside-out)
Use gentle friction
Don’t use gauze to clean across incision twice
REEDA
R: Redness
E: Ecchymosis (bruising)
E: Edema
D: Drainage
A: Approximation
How to Document Wound care
- What did you do and why
- Pain assessment (pre/intra/post)
- What dressing you took off the wound (drainage)
- Solution used to cleanse (usually saline)
- Wound assessment (REEDA)
- What dressing you covered wound with
- Patient tolerance
Risk factors for surgery
age
nutrition
obesity
immunocompetence
Fluid and electrolyte imbalances
Pre and Post Op Teaching
Deep breathing and coughing
Mobilization
Pain management
Anti-embolic stockings
Pneumatic compression stockings
Leg exercises
Informed Consent
procedure explained
risks/benefits
potential outcomes
recovery process and length
alternative treatment options
outcomes if procedure not performed
Common Types of Fractures
Closed
Open
Comminuted (fragments)
Displaced
Oblique
Spiral
Impacted
Green stick
Stages of Bone Healing
- Hematoma formation
- Granulation tissue
- Callus formation
- Osteoblastic proliferation
- Bone remodeling
Venous thromboembolism (VTE): Deep Vein Thrombosis (DVT)
Blood clot in the vein related to one of the endothelial injury, venous statis or hypercoaguability
Symptoms: asymptomatic, calf/groin tenderness, unilateral swelling with warmth, redness or edema
Bone or Soft Tissue Injury
Open fractures - more at risk of infection
Symptoms: tenderness or pain, redness, swelling, warmth, increased temp and pulse, purulent drainage, increased WBCs
Compartment Syndrome
Swelling in a limited space that compresses the muscles, nerves and blood vessels (internal or external pressure)
S&S: Pain, poikilothermia, pallor, paresthesia, paralysis, pulselessness
Fat Embolism Syndrome
Fat globules break away from the bone marrow and float into the bloodstream
S&S: hypoxemia, dyspnea and tachypnea, crackles, chest pain, decreased O2 states, petechiae rash in some patients
Chronic Complications from Surgery
Avascular necrosis (blood supply to bone disrupted causing decreased perfusion and death of bone tissue)
Delayed Union (fracture not healed after 6 months)
Complex regional pain syndrome
What are the majority of fractures caused by?
MVA or a fall
Health promotion/teaching about fractures
osteoporosis screening
fall prevention
home safety
dangers of substance use and driving
use of helmets
Fracture Assessment: Hx
- cause of fracture
- events leading up to injury
- substance use (opioids)
- occupational/recreational activities
Fracture Assessment: Physical, S&S
- trauma to other systems
- maintain adequate CSM, good body position
- pain management
- complications for early preventions
- VS and neuro checks
- Maintain skin integrity
- Ins and outs/ IV therapy
Fracture Assessment: Neurovascular
Color + Temp + Movement + Sensation + Pulses + Capillary Refill = Circulation, Sensation and Movement
Fracture Assessment: Lab and Imaging Assessment
Hemoglobin
Hematocrit
ESR
WBC
Serum calcium, and phosphorus
X-rays
CT
MRI’s
Acute Pain
ABC’s secondary survey (head to toe), analgesics
Bone Reduction
Realignment of bone ends for proper healing
Cast Care
Used to immobilize complex fractures
- fiberglass
- plaster
- walking
Traction
Skin traction uses a boot to realign joint - prevent bone spasms
Screws can be used to reduce fracture and provide bone realignment
ORIF
Open Reduction with Internal Fixation
Internal Fixation
Uses pins and plates to keep fracture immobilized
External Fixation
Allows swelling to reduce or wounds to heal before having closure completed
Fractures: Care coordination and transition management
Can the pt go home right now?
Home care management
Self-management education
Health Care resources
Fractures: Evaluate Outcomes
Pain control
Ambulates independently
Free of physiological consequences
Adequate blood flow
Free from infection
Hip Fractures
Osteoporosis is the biggest risk factor for hip fractures - 30000 per year in Canada
Types of Hip fractures
Intertrochanteric
Subtrochanteric
Femoral neck
Subcapital
Capital
Intracapsular (in joint capsule)
Extracapsular (outside joint capsule)
Hip Fracture Pre-op care
ABC’s and head to toe
VS
Neuro checks
IV with analgesic
NPO for surgery
Nay have traction for comfort
Hip Fracture post-op care
ORIF preferred
pain control
monitor for delirium, malnutrition, UTI, pneumonia, pressure injuries
Common post-op complications: CV system
hemorrhage - blood loss
Hypovolemia - low blood volume
Hypovulemic shock - inadequate perfusion of tissues
Thrombus/embolus - clot/dislodged clot
Common post-op complications: Resp System
Atelectasis - collapsed alveoli
Pneumonia - lung infection
Hypoxemia - low O2 in blood
Pulmonary Embolism - clot in lungs
Common post-op complications: GI system
Paralytic ileus - diminished or absent peristalsis
- abdominal distension
- nausea and vomiting
Common post-op complications: GU system
Urinary retention
UTI
Common post-op complications: Integumentary system
wound infection
wound dehiscence (separation of wound edges)
wound evisceration (protrusion of internal organs at suture line)
skin breakdown (pressure injury)
Patient Controlled Analgesia (PCA)
Self-administration of opioid analgesic
Push a button to release opioid by bolus via IV route
Orders written by anesthesia
Pump set up and monitored by RN’s
Key assessments: RR, sedation level, comfort level, O2 sats q4h
Epidural and Anesthetic post-op
Injection of anesthetic and narcotic agents into epidural space
Can be continuous infusion and/or pt controlled boluses
Key assessments: HR, RR, BP, sedation level, comfort level, O2 sats, sensory levels, motor function, epidural site q4h
Sedation Scale
S - normal sleep, easy to rouse
0 - alert
1 - sometimes drowsy
2 - frequently drowsy
3 - somnolent; difficult to rouse
Motor Function Scale
2 - no weakness
1 - some weakness of legs/feet
0 - unable to move legs/feet
Sensory Level
Dermatome levels - describe both sides
Wound prevention and management cycle
- assess/re-assess
- set goals
- assemble the team
- establish and implement a plan of care
- evaluate outcomes
Wound Management - Key factors
Wound cleansing
Debridement of healable wound
Moisture balance
elimination of dead space (packing)
thermal insulation
protection of periwound skin
Braden Scale
Friction/Shear
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Pressure injury stage 1
intact skin with non-blanching redness
Pressure injury stage 2
partial thickness loss of dermis, shallow ulcer
red/pink bed
without slough
could be intact or open
Pressure injury stage 3
Full thickness tissue loss
subcutaneous fat may be visible
bone, tendon, muscle NOT visible
May have undermining/tunnelling
May have odor/drainage
Pressure Injury stage 4
Full thickness tissue loss
exposed bone, tendon or muscle
slough or eschar may be present
often undermining/tunnelling
possible odor/drainage
Pressure Injury Unstageable
Full thickness tissue loss
base of ulcer covered by slough or eschar
extent of tissue damage can’t be confirmed
MEASURE
M: Measure (length, width, depth)
E: Exudate
A: Appearance of wound base (color)
S: Suffering (pain level)
U: Undermining or tunnelling
R: Re-evaluate
E: Edge
Suture Removal Steps
- Clean incision
- Grasp knot with forceps and cut opposite the knotted end
- remove alternate sutures and then remaining
- clean incision
- may use steri-strips
- Use REEDA to assess wound
Wound Irrigation and Packing
Clean out wound and fill space
Fluff, don’t stuff
Use MEASURE to assess wound
Wear face shield
Tips for Finding a Vein
Begin distally
Use non-dominant arm
Should be easily palpable - soft and full
Avoid areas with injury/procedures that were done
Tourniquet is placed 10-15 cm above desired vein
Documenting IV Insertion
- Size of needle/cathalon gauge
- Location of Start
- Pt tolerance
- Anything abnormal
How much of body fluid is plasma?
3 L
How much of body fluid is interstitial fluid (IF)?
10 L
How much of body fluid is Intracellular Fluid (ICF)?
28 L - 67%
How much of body fluid is extracellular fluid (ECF)?
32% (intravascular 8%, interstitial 24%)
How much of body fluid is transcellular?
1%
Osmolality
Total solute concentration in an aq solution
Tonicity
Cells affected by osmolality of fluid around them
What is Normal Saline Solution?
Isotonic
Hypotonic Solution
Conc is greater inside the cell than the solution - causes cell to grow and lyse
Hypertonic Solution
Conc is greater in solution than cell - causes cell to shrink
D
Dextrose
LR
Lactated Ringers
W
Water
NS
Normal Saline
IV Gravity Lines
Harder to manage (manual)
IV Pump Lines
Has occlusion monitor (easier to manage)
Primary IV Lines
“Maintenance IV Lines”
Secondary IV Lines
Attached to primary line
Documenting maintenance of IV fluids
- Type of solution
- rate per hour
- How many IV’s pt has
- IV fluid changes
- What you started in the IV
- Location of IV
- If pt is difficult/tolerance
Infiltration
IV fluid enters the surrounding space around the venipuncture site
Phlebitis
Inflammation of the vein
Fluid Volume Excess
Pt receives too much fluid
TF
Tubing drop factor (gtts)
Microdrip
60 gtt/mL
Macrodrip
Need to check package
10 gtt/mL
15 gtt/mL
20 gtt/mL
Calculating Gravity IV Drip Rates
(Number of mL to infuse / number of MINUTES to infuse) x TF = gtts/minute
Calculating IV drips for Infusions Pumps
Total number of mL ordered/Number of HOURS to run = rate in mL/hour
Determining hours an IV will run
Number of mL ordered/Number of mL/hour = number of hours to run
Cardiac Output equation
HR x SV = CO
Main Function of the Heart
Put out adequate volume of blood effectively enough to perfuse entire body
Why is HTN the “silent killer”
Because its usually asymptomatic until organ disease occurs
Hypertension (HTN)
Systolic P > 140mmHg
Diastolic P > 90mmHg
Pathophysiology of HTN
Genetics
Na and H2O retention
Stress and increased SNS activity
Altered Renin-Angiotensin-Aldosterone Mechanism
Insulin resistance and hyperinsulinemia
Primary HTN
Without an identified cause (90-95%)
Secondary HTN
With a specific cause (5-10%)
Solutions for HTN
- Assess risk, monitor BP regularly
- Encourage lifestyle changes (physical activity, weight reduction, less alcohol, less sodium, stress mgmt, smoking)
- Pt adherence to pain
- Drug therapy (decrease vascular resistance OR decrease circulating BV)
Overall goal for pt’s with HTN
To achieve and maintain target BP
Most common cause of CAD
Atherosclerosis - fat deposits in the inner lining of artery that obstruct circulation - thrombin generated when vessel is damaged
Stages of CAD
- Chronic endothelial injury: damaged endothelium
- Fatty streak: lipids accumulate
- Fibrous Plaque
- Complicated Lesion: Thrombus formation
Modifiable risk factors for CAD
Elevated serum levels
HTN
Smoking
Obesity
Inactivity
Metabolic syndrome
Diabetes
Stress
Chronic stable angina
Occurs intermittently
Same onset, duration and intensity
“pressure” or “ache”
3-5 mins
Types of Acute Coronary Syndrome
Unstable angina
NSTEMI
STEMI
Unstable angina
New in onset, unpredictable
No ECG changes
Increase in frequency
NSTEMI
non-ST segment elevation MI:
chest pain (severe)
diaphoresis, cool clammy skin
BP and HR increased initially
Elevation on ECG
Results in partial occlusion of artery
STEMI
ST segment elevation MI:
chest pain (severe)
diaphoresis, cool clammy skin
BP and HR increased initially
Elevation on ECG
Results in complete occlusion of artery
Virchow’s Triad
3 main factors that cause a thrombosis
1. Venous Stasis
2. Vascular injury
3. Hypercoaguability
