Patient safety Flashcards
1
Q
What are the 3 phases of wound healing?
A
- inflammatory
- proliferation
- remodeling
2
Q
What is the inflammatory phase?
A
0-3 days
3
Q
What would you see in the inflammatory phase?
A
redness, edema, phagocytosis
4
Q
What is the proliferation phase?
A
4-24 days
5
Q
what happens during the proliferation phase?
A
grannulation and epithelial tissue forms
6
Q
What do we need good levels of during the proliferation phase? why.
A
albumin levels. Cuz you need good albumin levels to form epithelial tissue
7
Q
What is the normal albumin level?
A
3.5-5
8
Q
What is remodeling phase?
A
24 days - 1 year
9
Q
What happens during the remodeling phase?
A
scar formation and contracture
10
Q
What are the 3 kinds of wound closure?
A
- primary intention
- secondary intention
- tertiary intention
11
Q
What are 1 considerations for primary intention wounds?
A
all layers of wound are approximated
12
Q
What are most surgical wounds with wound closure?
A
primary intention
13
Q
What are secondary intention wound closure?
A
you never intend to close the skin. It will heal from the bottom up.
14
Q
What is an example of secondary intention wound?
A
pressure ulcer
15
Q
Secondary intention wounds heal through what?
A
granulation
16
Q
What is tertiary intention also known as?
A
delayed primary intention
17
Q
Tertiary intention are left what?
A
open and packed
18
Q
Tertiary intention is left open because there is high suspicion of what?
A
infection
19
Q
What are you putting on tertiary intention wounds?
A
wound vac
20
Q
What are patient factors for wound healing?
A
- nutrition
- age - the young and the old are more at risk for any kind of infection
- Immunosuppression - NSAIDS (suppresses inflammation), steroids
- circulation/oxygenation - hypotension, diabetic, hypothermic
- comorbidities
21
Q
What are environmental factors that impact wound healing?
A
- length of surgery
- trauma
- prolonged stress - lifestyle or socioeconomic
- coagulopathies - hematomas
22
Q
Why do we not give aspirin and use tylenol instead?
A
aspirin suppresses inflammatory phase which is what we need to form epithelial tissue
23
Q
Why do we hold steroids?
A
increases glucose and feeds the bad bacteria
24
Q
What are indications of infection?
A
- redness
- edema
- tenderness
- fever
- leukocytosis (elevated WBC’s
25
In normal wound healing you wouldn't see which 2 symptoms
1. fever
2. elevated white count
26
How long does it take for microcontaminants to proliferate to where you would see clinical signs of infection from surgery?
1 week or more
27
What is a deep infection?
body cavity or in a joint
28
A deep infection occurs within how many days?
90 days
29
A superficial infection occurs within how many days?
30 days
30
Who determines the number of days to where you would see an SSI?
CMS
31
SSI's are what type of events?
never events
32
What are 3 wound healing complications?
1. separation
2. dehiscenece
3. evisceration
33
What is separation?
wound edges come apart
34
What is dehiscence?
separation to the fascial layer
35
What is there new development of with dehiscience?
drainage
36
What is evisceration?
abdominal contents spilling out
37
Why is evisceration so important?
because it is a surgical emergency
38
What can you have with evisceration?
ischemic injury and infection
39
What is considered class I?
primary closure. no break in technique
40
What is the infection rate of class I?
infection rate less than 5%
41
What is included in class 2 (clean/contaminated)?
includes cases in which GI, GU, Respiratory tract are entered under controlled conditions and without spillage
42
What are 4 examples of class 2 (clean/contaminated)?
1. bowel resection
2. hysterectomy
3. T&A
4. cholecystectomy for CHRONIC CHOLECYSTITIS OR FOR STONES NOT ACUTE
43
What is expected infection rate of class 2 (clean/contaminated)?
8-11%
44
What is class 3 (contaminated) is a break in what?
break in technique/spillage
45
What are examples of class 3 (contaminated)?
1. appendectomy for acute appendicitis
2. cholecystectomy for cholecystitis
46
What is expected infection rate of class 3 contaminated?
expected infection rate 15-20%
47
What kind of injury is class 3 (contaminated)?
fresh traumatic injury (<4 hours)
48
If you are doing an elective appendectomy what kind of class is it?
class II
49
If you are doing appendectomy for acute appendicitis what kind of class is it?
class III (contaminated)
50
If you are doing an appendectomy for a ruptured appendix?
Class IV (infected)
51
What is the expected infection rate of class IV infected?
27-40%
52
What makes a class IV?
puss, poo, or dead tissue
53
What are 3 examples of class IV surgeries?
1. I and D of abscess
2. ruptured appendix
3. GSW to abdomen
54
What would you see with class IV (infected)?
1. clinical infection
2. perforated viscera
3. necrotic tissue
55
If you put anything into a natural orifice but do not make an incision what kind of wound class is it?
no wound class or N/A
56
Patients should do what before and on the day of surgery to prepare for skin antisepsis?
should shower or bathe night before
57
What is the most effective type of solution to bathe or shower with?
4% CHG most effective
58
What is also good to bathe or shower with?
2% CHG impregnated cloths
59
How should you dry yourself after shower or bathe night before and day of surgery?
dry with a clean towel if shower or bath
60
Where should you not shower or bathe night before and day of surgery?
not on face
61
Product selection for skin antisepsis?
multidisciplinary team responsible
62
Why do we never put CHG on the face? mouth, ear
1. if it gets in your eye it sclerosis the cornea, which can cause permanent vision loss.
2. If it gets into your mouth, it can turn your teeth gray
3. If it gets into your ear, it can sclerosis the bones in the ear which can cause permanent hearing loss
63
What do we remove from the surgical site?
jewelry, makeup
64
What skin prep do we use for gram-positive MRSA?
hexachlorophene or visahex
65
What are 2 considerations for hexachlorophene?
1. Not for premature babies
2. It is not broad spectrum. It only kills gram positive, not gram negative
66
What skin prep do we use for VRE?
chlorhexidine
67
What skin prep do more people react to before any other prep?
chlorhexidine
68
What do we do preoperatively with colonization?
decolonization preoperatively
69
Verify what before you prep?
site
70
Hair removal at site only in what?
select clinical situations
71
Hair should be left what?
in place
72
Use what to remove hair when necessary?
clippers or depilatory creams
73
How do we want to remove hair?
remove outside of the OR or in a manner that prevents dispersal of hair into the air
74
What are preferred for hair removal?
disposable clippers
75
Remove what superfical before what?
superficial dirt and debris from skin before prep
76
Can alcohol and chloroxylenol or para-chloro-meta-xylenol (PCMX) pennetrate organic material like body oil or blood? (you need something with soap suds)
no
77
Areas of greater contamination should be what?
cleansed before prep
78
Isolate highly contaminated areas with what?
a sterile barrier drape
79
Prep should be done by someone who is what?
not scrubbed in
80
What kind of gloves do you use for sponges?
sterile gloves
81
What kind of gloves do you use for long applicator?
non-sterile gloves
82
What do you want to cover when prepping? why?
long sleeves to prevent shedding
83
How do we prep?
prep from incision to periphery
84
What 3 things do we use providone iodine on?
perineum, eye, or ear
85
If you have an iodine allergy use what for prep for perineum?
PCMX (technicare) or 3% H202
86
If you have an iodine allergy, what can you use on eyes?
normal saline
87
If you have an iodine allergy, what prep can you use for ears?
normal saline or PCMX
88
What 3 things should a prep be?
broad spectrum, fast acting and persistent
89
The surgical site mark should remain after what?
prep
90
No unprepped skin should show through the what?
fenestration in the drape
91
Prep should be removed from skin outside of what? because?
dressing because it causes skin breakdown
92
When you have a highly contaminated sites how do you prep?
prep low count area incision to periphery then highly contaminated site last
93
Let's say we have open tib-fib fracture
edge of wound out, and with last applicator you do inside of that wound
94
What if we need to prep an ostomy, how do we do this?
cover an ostomy in the site with a sponge soaked in prep solution, and then prep incision to periphery concentric circles outward
95
How do you do a proper abdominal/perineal prep?
1. prep perineum first with 10% providone idoine extending to pubis
2. paint only on perineum
3. prep abdomen with antiseptic solution
4. apply same prep along the boarder of prepped abdomen and perineum
96
What is the recommended by AORN as primary choice for skin preps?
alcohol based skin preps
97
What must alcohol based skin preps be in order to be effective?
dry
98
What is recommended before alcohol based skin prep?
hair removal
99
What 2 preps can cause corneal damage?
alcohol and CHG
100
No pooling or saturating of alcohol based preps on what 3 things? what 2 things can it cause?
1. Electrodes, towels or drapes
2. fire hazard and chemical burns
101
True or false: multiple applications of alcohol based agents is not recommended
true
102
What is a subcostal/kocher incision for?
anything biliartry like open gallbladder
103
What is a left subcostal incision for?
splenectomy
104
What is a transverse incision?
horizontal incision anywhere on the abdomen
105
Above the umbilicus, a transverse incision is called what?
transverse abdominal incision
106
Below the umbilicus, a transverse incision is called what?
low transverse abdominal incision
107
Faninstill is a type of what?
low transverse abdominal incision for c-section or abdominal hysterectomy or something in the bladder
108
What is a paramedian incision?
vertical incision on the abdomen for unilateral organs.
109
What is mcBurney's incision for?
appendectomy
110
What is the difference between indirect and direct hernia?
HESSELBACH triangle is made up of ligaments, muscles, and vessels.
If you have direct inguinal hernia it means it is coming out through HESSELBACH's triangle.
If you have an indirect inguinal hernia it means it is NOT coming through HESSELBACH's triangle.
111
what is an incarcerated hernia?
one that you can't reduce. You can't push it back through. it is an emergency!
112
What is pro of a midline incision?
a bloodless field, you aren't worrying about nerve damage because you are not working through fussy abdominal muscle, less painful.
113
What is a con of a midline incision?
dehiscence evisceration are more common
114
what is a chevron incision for?
Exposure of the liver
115
We should only dispense medications...
when needed. Pull it up right before you give it
116
Do not remove what from medication vials?
rubber stoppers.
117
Use a what to put meds on the field?
a sterile transfer device
118
Limit use of what for medications?
multi-dose vials
119
Multi-dose vials are good for how many days?
28 days
120
Multidose is for how many patients?
one patient
121
Verify meds with who?
scrub tech or RNFA
122
If a med is set down on the field for a moment, it has to be what?
labeled
123
If a med is drawn up from the field and immediately given does it need to be labeled?
no
124
What does a label of a medication on the field have to have?
name, concentration, date, and time
125
What do we keep in regard to meds throughout the case?
keep med containers throughout the case
126
Relief personnel should verify all what?
meds and labels
127
Scrubbed person is responsible for knowing what for the surgical counts?
for knowing how many sponges are inside the patient at all times
128
Counts are done by how many people? and who must one of them be?
two people, one should be an RN
129
Count in what?
sequence
130
Sequence of count is defined by what?
facility policy
131
What is usually the sequence of the surgical count?
surgical site, mayo stand, back table, and then off field
132
Pocketed sponge holder has to have what?
background color
133
Scrub person should be doing what while audibly counting?
separate and point out items on the field
134
The RN circular should be doing what while audibly counting?
separate and point out items on the field
135
There should be what in every room?
visible count board
136
Run count in only what?
only one place
137
Ideally only count worksheet is what?
visible count board
138
Place retractor/packed sponges on what?
count board
139
Additional count at what?
designated intervals during long procedures (all day)
140
Counting in intervals during long cases is up to what?
our hospital policy
141
What does AORN recommend for additional counting as far as timing ?
3-4 hours into the procedure
142
If interrupted during count what must happen?
recount that item
143
If there is a discrepancy what 2 things should be done?
1. first make team aware
2. second recount
144
What do we do if we really can't find a missing item?
search for it.
145
If a missing item is found, what do you do?
recount that item
146
If a missing item is not found, what do you do?
radiology and surgeon look at x-ray together
147
Trash should not be what?
removed from room until patient leaves
148
What can you use in addtion to a audible surgical count?
adjunct technology
149
What should adjunct technology be?
1. FDA approved
2. according to manufacturer's instructions for use
150
Can adjunct technology be waived for certain procedures?
yes
151
you want to implement adjunct technology all over the facility at what?
the same time
152
Use the adjunct technology even when...
you think the count is correct
153
Never open sponges in a room that are not what?
part of the count
154
Package of sponges containing an incorrect number must be what?
isolated from the field, bagged and labeled
155
HOSPITAL POLICY can delete counts from what?
a specific procedure (like cysto, ophthalmology, ALIF)
156
Can you cut sponges?
no
157
Use only what kind of sponges during surgery?
x-ray detectable
158
Use what kind of communication the number of needles added to the field and the number added to the count board?
read-back method
159
What is a frequent retention object?
guidewire
160
Use what kind of confirmation that guidewires are removed and intact?
verbal confirmation
161
What should be part of the hand off communication for a wound vac?
number of pieces within wound
162
Open instruments removed cannot be what?
cannot be in the OR uncounted
163
Standardize instrument sets with what?
number of and types of instruments
164
If something is broken it must be what?
accounted for in its entirety
165
Minimally invasive surgical instruments need what?
additional monthly inspection
166
What do we have to count with vaginal antisepsis?
prep sticks
167
We should be doing methodical what inside of a cavity?
exploration
168
If the vagina is entered during surgery, should we do methodical exploration?
yes
169
Is the vagina a frequent retention site?
yes
170
What are the 6 things we document with counts?
1. type and number of counts
2. name and title of persons performing the count
3. notification of surgeon
4. instruments remaining with patient or sponges intentionally left as packing
5. actions taken if there is an unresolved count
6. rationale if counts are not performed or completed
171
What should we add if there is intentional packing?
add an order set for removal of packing into patient's chart
