Asepsis Flashcards
how are wounds characterized?
cause, severity of tissue damage, cleanliness
when assessing wounds, need to assess and document what?
*type of wound (acute/chronic, pressure ulcer/surgical wound, intentional/contaminated)
*location
*appearance (open/closed)
*tissue types and amounts (granulation, slough, eschar %)
*Periwound assessments (RITA)
*staples/sutures/glue?
*size (LxWxD)
*tunneling/undermining with clock positioning
*tissue damage (full, partial)
*drainage/exudate (COCA)
*drains/tubes?
*dressing removal
*wound cleaning? Or irrigation?
*new wound dressing/materials
*patients response (tolerance, pain scale during/after)
*education (pt was educated on the importance of repositioning and increasing protein intake)
acute wounds heal in about _______
2-4 weeks, otherwise they’re considered chronic
wound size is measured in what unit?
centimeters
abdominal pad
AKA: ABD
*high absorbency
*used as a secondary dressing
non-adherent dressing
mild-moderate drainage
Example: Telfa or Bandaid
transparent dressing
Self-adhesive
Semipermable
Traps moisture
good for IV dressings
Ideal for small superficial wounds
foam
moderate to heavy exudate
Provides thermal insulation and protection
Does not stick to wound
Example: Mepilex (Foam with adhesive border)
alginate dressing
Heavy Exudate Absorbers
Forms soft gel while absorbing drainage
Not for dry wounds
hydrocolloid
Occlusive hydrophilic (water loving)
changed every 3-5 days
maintains moist healing, can be used in clean and necrotic wounds.
For light to moderate drainage
Can mold to shape of body (heels, buttocks)
Ex. Tegasorb, duoderm
hydrogel dressing
Gauze of sheet dressing impregnated with water or glycerin
High water content creating jelly like consistency that does not adhere to wound bed
Promote moist environment and rehydrate wound bed
For minimal drainage
Jackson-Pratt
bulb, constant pressure, closed drainage device
Hemovac
circular with spring, constant pressure, closed drainage device
Wound Vacuum Assisted Closure
packed black foam, Suction and negative pressure facilitates healing
Dressing changed 3 times weekly, drainage canister changed weekly or as needed
Culturing a wound; what drainage do you collect?
clean the wound first b/c you don’t want old drainage
Stage 1 pressure injury
Nonblanchable Erythema of intact skin
Stage 2 pressure injury
Partial Thickness Skin Loss
*Presents as a shallow open ulcer with a red-pink wound bed
*No slough.
*Can present as an intact or open serum-filled blister
*Shiny or dry
Stage 3 Pressure Injury
Full Thickness Skin Loss
*subq and adipose exposed
*may be slough or eschar
*bone/tendon/muscle NOT exposed
*may have undermining/tunneling
Stage 4 pressure injury
*full thickness loss
*Bone, tendon, or muscle exposed or directly palpable
*slough or eschar, maybe
*undermining and tunneling common
*often requires a year to fully heal
urine: freshly voided (purpose?)
This method is used when identification of bacteria or infection is not required.
urine: sterile specimen
*how to obtain sample?
*what’s it used for?
*clamping a drainage bag and withdrawing with a syringe OR using a straight cath
*urine culture
what can be identified with a stool sample?
infection, parasites, and presence of blood
what can be identified with a nasal swab?
MRSA, influenza and RSV
what do you swab when obtaining a wound sample?
first clean wound, THEN swab area of red granulation in wound bed
