Last Week Stuff Flashcards
Is some escape of blood from a wound normal?
Yes
Hematoma =
A localized collection of blood - appears as reddish blue swelling
How can internal hemm be detected?
Swelling or distension in area of wound and possible sanguineous drainage from surgical site
When is greatest risk for hemm post op?
First 48 hours
What systemic factors predispose someone to infection?
Vascular disease Edema Malnutrition DM Alcoholism Prior sx or radiation Drugs (steroids) Inherited immune defects
Local factors that predispose someone to infection?
Large wound area Increased wound depth Degree of chronicity Antomical location (distal extremity, perineal) Presence of foreign bodies Necrotic tissue Reduced perfusion Degree of postwound contamination
Additional signs beyond the cardinal ones that are subtle indications of infection of a wound?
Friable (jelly-like) granulation tissue
Unstable epithelial bridges
Failure to respond to therapy
Health care-assocaited infections that occur in post surgical pts = ?
Biggest cause of this?
SSI’s (surgical site infections)
Mostly d/t pt’s own flora entering surgical site
Risk factors for SSI?
Hyperglycemia Smoking Prolonged preoperative hospital stay Using shaving for hair removal Intra and post-operative hypothermia (less than 36 degrees)
When is an SSI most likely to become evident?
2-11 days post-op
Are systemic antibiotics used for pressure ulcers that display only local signs of infection?
No - but may be used for bacteremia, sepsis, advancing cellulitis, or steomyelitis
* Topical antibiotics can be used may be given a 2-week trial in case of clean p ulcers that do not show evidence of healing or are continua=ing to produce exudate after 2-4wks of optimal treatment
What is nurse to do with hemmorhage?
Is emergency! Apply extra sterile pressure dressings to area and monitor client’s vital signs. Likely to need stat operation
What factors heighten client’s risk of wound dehiscence?
Obesity Smoking Poor nutrition Multiple traumas Failure of suturing Excessive coughing Vomiting Dehydration
- Those at risk may be prescribed abdominal binder for suppport
When is dehiscence most likely to be seen?
4-5days post op, before extensive collagen is deposited in the wound
What might indicate impending dehiscence?
An increase in the flow of serosanguinous drainage into the wound dressing
How to position patient if dehiscence occurs?
In bed with pt knees bent to decrease pull on incision.
When donning sterile gloves, always make sure to have ____ when preparing for the procedure?
An extra pair
Which hand do you donn gloves onto first?
Dominant hand
When donning the first glove, what surface of the glove are you touching?
Only the inside
How to position hand when donning gloves to ensure don’t contaminate outside?
Keep thumb tucked against palm
Should you unfold the cuff of the glove?
No, leave cuff turned down to avoid risk of contamination
Complications that drains are assoc with?
Hemorrhage
Tissue inflamation
Retrograde bacterial migration
Drain entrapment
What are drains
What the differenced between closed and open drains?
Perforated silicone tubes which exit through the surgical incision or through a separate small stab wound
drain either into a sterile vacuum device (closed drain)
Or into dressings (open drain)
Why are those drains situated away from the primary incision preferable to those that exit the wound itself?
help to prevent transmission of infectiosn between operation site because can dress them separately
Diff between superficial and deep drains?
Superficial = placed in the wound Deep = may be intra-peritoneal, in a hollow organ or duct, or positioned in deep cavity such as abscess or haematoma
Why are drains used?
Prevent formation of haematoma
To remove accumulation of fluid
- Primary purpose is to drain blood or serous fluids that may become infected and result in tissue irritation and breakdown of overlying tissues
- May also be used to monitor leakage (eg: bile leak following biliary operations) or to divert body fluids away from particular surgical site
When are drains removed?
When drainage has ceased, typically 24-48hrs following surgery (if used to cover perioperative bleeding and hematoma formation)
- If drain inserted to prevent accum of serous fluids, removal will depend on size and nature of wound and potential for complications
- Decided by surgeon
Are blocked drains removed? Why are drains removed as soon as possible?
Yes
In order to limit risk of infection + so granulation tissue doesn’t develop around drain
When might a sample be taken of wound with drain removal?
May be useful in pts whose drain sites may be infected or in pats who are pyrexial
How to monitor discharge from drain site post removal once dressing is applied?
Draw line and put date so can see how rapidly this leakage is occuring
When are dressings applied post drainage removal typically removed?
3-5 days (when drain site has healed)
Use of ____ technique is essential when caring for and removing drains?
Aseptic (not sterile?)
Procedure for drain removal
- Remove dressing with clean gloves + throw away
- If has vacuum bottle, clamp tubing to release vacuum
- Note amount of drainage in bottle
- Put on sterile gloves
- Cleanse site if necessary
- Place sterile dressing under drain tubing
- Remove sutures if necessary
- Fold up sterile gauze swab and position over drain site
- Warn pt of pulling sensation
- Grasp drain close to skin using sterile gloved hand or forceps
- Gently withdraw drain onto sterile towel
- Check that entire drain has been removed
- Maintain p on site until bleeding and/or drainage is minimal
- Dress with sterile dry dressing
What supplies are needed for shortening a drain?
Clean gloves • Sterile gloves • Face shield • Dressing supplies • Dressing set • Suture removal supplies (if required) • Sterile pin • Sterile forceps • Sterile normal saline • Sterile scissors
How do you know how much to shorten a drain?
drs orders
Procedure for shortening a drain
Clean incision and drain area with sterile
normal saline.
- If drain is sutured, remove sutures.
- Support skin around drain site with sterile forceps. Using second sterile forcep, pull
ordered amount of drain out. Move supporting forceps to bottom edge of visible
part of drain. Using second forceps, insert new sterile pin into drain close to bottom
of visible drain (see Figure 1). Leaving 2 cms of drain above newly inserted pin, take
sterile scissors and cut drain between the 2 pins (see Figure 2).
