Perioperative and skin integrity Flashcards
perioperative nursing involves the care of clients ___, ___, and ___ surgery and some other ___ ____
aka?
before, during and after
invasive procedures
aka operating room nursing
Who governs perioperative nursing practice?
AORN, joint commmission, medicaid, national priorities partnership, institute for healthcare improvement
These are called?
wrong patient, wrong site, wrong surgery, DVT or PE after knee or hip replacement; foreign body; surgical site infection
never events
Surgeries are classified by:
body system
purpose
degree of urgency
degree of risk
purpose... ablative? diagnostic? palliative? cosmetic? transplant? harvesting?
ablative-removal diagnostic or exploratory-confirm diagnosis palliative-relieves discomfort reconstructive-restores fx cosmetic-appearance improvement transplant-replaces malfx. organ harvesting-removing organ
emergent surgery happens…
within 24 hours if not immediately
urgent surgery happens within…
24-48 hours
elective surgery
has more time
risk? major or minor?
major-greater risk; higher infection risk
minor-lower risk
factors that contribute to surgical risk?
age, personal habits; allergies; type of wound; preexisting conditions; mental status; medications
preoperative screening tests
CBC, urinalysis (specific gravity tells hydration level), ECG (tells if heart rhythm is normal)
Intraoperative team…
sterile team
made up of surgeon, surgical assistant, RN 1st assist
Interoperative team…
clean team
anesthesiologist, CRNA, circulating nurse
time out
final verification of correct client, procedure and site
general anesthesia
most risk; loss of sensation; someone else maintaining airway; rapid unconsciousness
conscious sedation
IV sedation without unconsciousness; not necessarily in OR; can maintain protective reflexes
regional anesthesia
alert but numb; nerve block; spinal block, epidural; can’t feel (interrupts nerve impulses to and from area of procedure)
local anesthesia
loss of pain sensation at the desired site; minor procedures
PACU
postanesthesia care unit; immediate postoperative phase; aka post anesthesia phase
includes: recovery from anesthesia, airway management; vital signs/LOC; dressing assessment/drainage; fluid therapy; pain control
post op risks
surgical site infection; pneumonia; fall; pain; DVT
epidermis made up of
stratum corneum–outermost layer of skin
stratum germinativum–innermost layer; mostly new cells
what maintains the skin, repairs minor defects and preserves intravascular volume?
protein
what nutrition wise helps with the formation of collagen?
vit C, zinc, copper
what leads to increased risk for pressure and breakdown?
diminished sensation
what negatively affects tissue metabolism?
impaired circulation
medications can cause what side effects to the skin?
itching
rashing
Moisture leads to?
maceration–softening of the skin
two most common sources of moisture are?
fever and incontinence
fever depletes ___ and increases ___ ___
moisture
metabolic rate
open wound
break in skin or mucous membrane
closed wound
no breaks in the skin
acute wound
s/t; heals quicker
chronic wound
L/t; longer duration to recovery
clean wound
expected to be short duration; heal spontaneously
contaminated wound
open, traumatic wound or surgical incision in which a major break in asepsis occurred
infected wound
bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue
superficial wound
involve only the epidermal layer of the skin
partial thickness wound
extend thru the epidermis but not all the way through the dermis
full thickness wound
extend into the subcutaneous tissue and beyone
penetrating wound
wound involves internal organs
serous exudate
straw colored
sanguineous exudate
bloody drainage
serosanguineous
mix of bloody and straw
purulent
yellow, contains pus
regenerative healing
when the wound affects only the epidermis and dermis, regenerative/epithelial healing takes place; no scar
primary intention
clean surgical incision/ edges approximated; minimal scarring
secondary intention
wound edges not approximated; tissue loss; heals from inner layer to surface
tertiary intention
granulating tissue brought together; delayed closure of wound edges; increased risk of infection
complications of wound healing
hemorrhage; infection; dehiscence (pops open); evisceration (emergency; things protrude thru like bowel); fistula formation (abnormal passage; most common between GI and GU tracts)
Braden scale based on
Total score…..= risk
sensory perception, moisture activity mobility nutrition friction or shear
<18
debridement
removal of devitalized tissue or foreign material from a wound
sharp debridement
uses a sharp instrument to remove devitalized tissue
mechanical debridement
naturally remove with irrigation or hydrotherapy (book–lavage, wet to dry dressings or hydrotherapy (whirlpool))
enzamatic debridement
uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound (ointment with enzymes; clean first; cover with moisture containing dressing)
autolysis debridement
use of occlusive moisture retaining dressing and the body’s own enzymes and defense mechanisms to break down necrotic tissue; slow process
Jackson Pratt drainage device or Hemovac
compress device to create suction and facillitate removal of drainage
hydrocolloids/hydrogels
thick foamy dressing
gel dressing to retain moisture
binders
hold abdominal wound together
pressure ulcer
caused by unrelieved pressure to an area resulting in ischemia
