Final Exam Flashcards
Describe the common features of each: primary intention, secondary intention, and third intention.
Primary intention (primary union) - A clean, approximated incision that is closed with a suture or other appropriate product. No discharge from wound or tissue loss. Nominal scar formation.
Secondary intention - The wound heals by granulation, leading to wound contracture. Repeated debridement may be necessary. Infection and tissue loss are present. Scar formation and contracture may result in scar revisions.
Third intention (delayed primary closure) - Delayed wound closure due to considerable tissue loss and/or gross infection. Wound is not devascularized. Deep sutures are not used to avoid granuloma formation. Wound is cleaned, debrided, and packed. Eventual approximation of clean granulation surfaces is achieved.
How can the patient’s health influence wound closure and healing?
A patient’s health can influence wound closure and healing based on their nutrition and the presence of co-morbidities. If a patient has diabetes and experiences malnutrition, it negatively impacts wound healing due to the effects of the processes on the body, which creates a poor state for the body to adjust. This makes the body more susceptible to SSIs.
Does your facility provide NPWT devices? Where are the devices stored? Are all of the supplies needed for the application of this dressing stored together? If not, where else would you need to go in order to have everything for the surgeon? How do you enter the patient charge for the use of this device? Is there additional paperwork that must follow the patient to the subsequent nursing units?
Yes, the facility does provide NPWT devices.
They are stored within the normal storage room.
All of the supplies needed are stored together.
Wound Designation Chart
Intentional
-Surgical: an incision made into intact tissue
Unintentional
-Traumatic: can be life-threatening or non-life threatenting injuries
-Incidental: pressure-related injury that is caused by compromised circulation from inadequate, inappropriate surgical positioning
-Chronic: chronic pressure injury, can be caused by tissue loss from either arterial insufficiency or venous
Suture Material Classifications
Natural or synthetic material
Absorbable or non-absorbable suture strand
Monofilament or multifilament
Suture Material Characteristics
Physical configuration
-Mono or multifilament
-Coating
-Capilarity: capability of fluid that is absorbed by suture to be transferred along length of suture
-Diameter: suture size defcreases as the zeros expressing the size increase (3-0 is smaller than 2-0)
-Tensile strength: measurement of the suture strand’s ability to resist breakage
-Knot strength: force required to allow a knot to slip on itself
-Elasticity: measurement of the suture’s ability to recover its primary form and length after stretching or other deformation
-Plasticity: measure of the suture’s capability to be stretched, tied, or misshapen without breaking and maintaining the new form
-Memory: inherent capability of suture to keep/return its original shape
-Knot tensile strength: breaking point of a knotted suture
Handling: suture’s bending ability and how easily a suture can move through tissue and be tied down
-Pliability: how easy suture bends
-Tissue drag: how easy suture slips through tissue (lower drag = more easy)
-Knot tying: how easy suture can be tied (more friction = more difficult)
-Knot slippage: ability of knots to be slid down suture (bad ability = no wound approximation)
Tissue Reaction
-Inflammation
-Absorption
-Infection potential
-Allergic reaction
Stich Types
Interrupted: single sutures that are tied independently
Continuous/running stitch: uninterruped suture line
Retention suture: a heavy suture that reinforces the primary suture line
Subcuticular stich: a suture line under the epidermis
Purse-string: a suture placed around a circular wound
Skin Closure Options
Staples
-Advantages: easy to use, proiders uniform incisional tension, faster wound closure
-Disadvantages: requires extraction unless staples are absorbable
Adhesives
-Advantages: reduced risk of infection, less scarring, eliminates skin closure device removal
-Disadvantages: limited to use for superficial wounds, higher allergic reaction rate, not optimal for slow-healing conditions
Adhesive strips
-Advantage: less expensive than other closure methods
-Disadvantage: can loosen with moisture, causing wound compromies
Zippers
-Advantage: skin stretching forces are distributed over a wide surface area; away from the wound edges, may replace the need for a tissue expander, faster application than suture, may provide a more cosmetic outcome
-Disadvantage: cost, may not be an optimal option in the obese population
SSI Categories
Superficial incisional
-Epidermis, dermis, subcutaneus layers
-Within 30 days after surgery
Deep incisional
-Fascial, muscle layers
-Beyween 30 and 90 days after surgery
Organ/space
-Organ/space
-Between 30 and 90 days after surgery
Negative Pressure
Wound therapy used for difficult wounds that ahve not esponseded to other care methods
A specialized device applies constant, controlled, negative pressure to a wound into which a drianage spone has been placed
Mechanical tension on tissue
-Reduces edema
-Decreases bacterial load
Macro deformation
-Wound contracture
Micro deformation
-Microscopic interaction between the wound tissue and the dressing
Drains
Used to provide an exit for blood, serum, bile, air, intestinal secretions, and pus
Create a portal of entry for pathogenic microorganisms
Aseptic technique is necessary when emptying closed systems and changing a wound drain dressing
Simple
-Penrose drain
Closed suction
-Hemovac
-Jackson-pratt
-Chest tube
What are the goals of hemostasis?
There are 7
Decresae and control bleeding
Minimize the need for blood replacement
Optimize the surgical field view
Avoid major organ damage
Shorten the length of surgery and length of facility stay
Decrease the risk of infection
Decrease health care costs for patietns and facilities
Risks of Impaired Hemostasis
Impaired visualization of the surgical field
Increased surgical time
Necessity of blood transfusion
Risks
-SSI
-Systemic inflammatory response syndrome
-Transfusion related acute lung injury
-Multiple organ failure
-Increased mortality
What promotes a Culture of Safety?
The healthcare organization’s commitment to patient safety above all goals
A commitment to safety at all levels of the organization
A focus on systems, process improvement, and individual accountability
Sufficient resources
The ability of providers to discuss near-miss events and errors without reprisal
Patient Safety Movement
As a result of landmark reports, there has been a shift from a culture of placing blame on an individual when errors occur to creating safer health care systems and standardizing processes (e.g. use of checklists, communication tools)
Patient Safety Efforts
The parts of Universal Protocol in order for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery consists of three key steps:
-Conducting a pre-procedure verification process
-Making the procedure site
-Performing a time out
What is a skill-based behavior error?
The provider has the knowledge for the action but there is little or no attention, or attention is diverted
What is a knowledge-based performance error?
Errors in perception, judgment, inference, or interpretation
What is a situational factor error?
Lack of attention and situational factors play a significant role in this type of error
What processes demonstrate that a healthcare organization is committed to a culture of patient safety?
Accountability, creating a learning environment, and forming reliable teams for patient action
What is an example of a situational factor error?
The RN is distracted by music, conversation, equipment noise, or alarms going off
What is an example of a skill-based behavior error?
The nurse forgets to retrieve a unit of blood when called to conduct a sponge count
What is an example of knowledge-based performance error?
The RN assumes an adult medication dosage applies, but the patient is a child
What are the components of perioperative patient safety?
A safe environment
Appropriate staffing levels
Correct instrument care and cleaning
Fire safety
Infection prevention
Patient-centeredness
Prevention of patient falls
Prevention of sharps injury
Safe patient handling and movement
Sharps safety
Teamwork
What are the components of perioperative patient safety?
A safe environment
Appropriate staffing levels
Correct instrument care and cleaning
Fire safety
Infection prevention
Patient-centeredness
Prevention of patient falls
Prevention of sharps injury
Safe patient handling and movement
Sharps safety
Teamwork
What are the types of perioperative environment zones?
Unrestricted zone
Semi-restricted zone
Restricted zone
What is an unrestricted zone?
Anyone is allowed in this zone
Street clothes are permitted in this area
Ex. public hallways and patient waiting areas
What is a semi-restricted zone?
Secured from public access by signage, doors, and security measures (e.g. badge access)
Wear clean surgical attire, a head cover, and facility-approved shoes
Ex. hallways adjacent to operating room, sterile supply storge areas, and the sterile processing department
What is a restricted zone?
Areas that are separated from semi-restricted doors where access is controlled with limited entrance
Ex. operating rooms
Clean surgical attire and PPE is required to be worn
What is the basic team in the OR?
Surgeon, assistant, and scrub person at the sterile field
RN circulator and anesthesia professional, who are not a part of the sterile field
What are the axillary roles in the perioperative experience?
Allied health personnel
PACU RNs and team members
Perianesthesia RNs and team members
Pharmacists, other physicians
Radiology and laboratory team members
Support personnel
What is team communication?
Standardized preoperative verification and communication processes that should be followed to prevent wrong patient, wrong site, and wrong procedure events
What is part of the preoperative verification process?
Include the patient in the verification process and use standardized safety checklists
Patient identification
-Always use at least 2 patient identifiers
Surgical site marking
-The surgeon or proceduralist marks the site of the surgery
Time out
- Pause in patient care immediately before the procedure begins to conduct a final assessment of the patient
-Conduct a time out before the start of regional block, surgery, or other invasive procedure
What are the components of the fire safety triangle?
An ignition source (ex. electrosurgical pencil)
A fuel source (ex. surgical drapes)
An oxidizer (ex. oxygen)
When do you perform a fire risk assessment?
Before starting surgery
What are life safety events in the OR?
Fire in the OR
Malignant hyperthermia crisis
Local anesthesia systemic toxicity (LAST)
Cardiac arrest
Latex allergy
Who is at risk for MH complications, what are the S/S, and how is it treated?
Patient’s who have a genetic history of reactions with anesthesia are more susceptible to MH. The gene for MH is autosomal dominant.
S/S: increase in ETCO2, muscle rigidity, increase in temperature, and ultimately results in cardiac complications
It is treated with an IV push of dantrolene sodium (mixed with sterile water). After dantrolene is administered, current s/s are treated, such as hyperkalemia.
Who is at risk for LAST, what are the s/s, and how is it treated?
Patient’s undergoing the use of blocks (i.e. bier block) are at risk for LAST. LAST occurs when a large amount of local anesthetic enters the systemic bloodstream, resulting in toxicity.
S/S: periorbital numbness, change in hearing, and metallic taste
Treatment is the use of 20% lipid emulsion and then treating any current displaying s/s. Late signs include seizures and cardiac activity.
How can you prevent patient falls?
Assess patients for their risk for falls
Implement fall prevention practices
Document fall precautions
What are 3 ways to prevent patient falls in the perioperative setting?
Don’t leave the patient unattended in the OR until securely locked
Use of safety strap
Make sure both bed and stretcher are locked when transferring patient
What are 3 ways to prevent a fire in the OR?
When bovie is not in use, make sure to put it in plastic holster
Do not allow pooling of skin prep
When ignition sources are used, make sure they are on the lowest setting needed
What is asepsis?
The absence of pathogenic microorganisms
What is sterility?
The absence of virtually all microogranisms
What is biofilm?
The accumulation of bioburden, which is composed of bacteria and other biological elements
Is the result of a tight adhesion of bioburden to the instrument’s surface
Inhibits the ability of cleaning solutions and disinfectants to effectively decontaminate the instrument
Prevents successful sterilization
What are the actions to take before transporting a patient to PACU?
Discard sharps into a sharps container
Discard liquids per regulations and transport them in a leak-proof container
Separate sharp instruments from delicate and heavy instruments
Follow IFU for instrument disassembly prior to transport to decon
Moisten instruments with an enzymatic pre-treatment product or cover with a water-soaked towel
What are examples of mechanical cleaning equipment?
Washer-Disinfector/Decontaminator
-Combines mechanical, thermal, and chemical actions
-Cycles are specfic to the instruments being cleaned
Ultrasonic Cleaners
-Removes soil from hard-to-access areas of the instrument by caviation
-Cavitation is use of high-frequency sound waves that form microscopic bubbles that become unstable and implodes, creating small vacuums that remove debris from the instrument’s crevices and surfaces
What are the characteristics of water temperature in sterilization?
Temperature indicators are used in decon sinks to ensure water is in appropriate temperature rage, as determined by cleaning solution manufacturer
Cool water use prevents blood coagulation in instruments and helps to remove gross soil from instrument crevices, joints, and lumens
-Hot water can denature blood proteins which makes blood removal more difficult
Follow detergent IFU for details on amount of product needed and appropriate water temperature
What are biological indicators (BIs)?
Is used to monitor the sterilizer’s efficiency and effectiveness
This test demonstrates whether sterilization conditions were adequate to kill non-pathogenic spores housed within the BI
Negative BI indicates that the sterilization conditions were met
What are the characteristics of packaging system weight?
An instrument set and container cannot weigh more than 25lbs
If it weights more, it can require longer drying times
Heavier sets can increase risk of injury to healthcare personnel
Follow IFU for method and weight of loaner instrument or device set
What are the considerations of BIs?
BI must be specific to the sterilization method
BI quality tests should be performed at least weekly
An ethylene oxide-specific BI is included with each EO load run
A BI must be included with each sterilization load that contains one or more implants
-Implant package/set is not released for use until BI test results are known
A positive vial from same lot is incubated as test vial
A positive BI result is immediately reported. sterilizer is not used, items processed in same sterilizer are recalled and reprocessed based on last negative BI test, further testing is done before sterilizer is cleared for use
What determines shelf-life?
Shelf life of processed instruments is event-related
What are event-related elements that impact sterility?
The type of packaging
Storage conditions
Package/tray transport methods
Frequency and method of package/tray handling
What are the critical concepts of immediate use steam sterilization (IUSS)?
The same cleaning and decontamination processes must be followed in the sterile processing department per manufacturer’s IFU
US FDA-approved rigid, enclosed sterilization container must be used
Items processed by IUSS must be transported to point of use and not stored for future surgical procedures
