Skills Exam 6 Flashcards
what is sterile technique?
(also known as surgical asepsis)
- prevents contamination of an area
- open wound
- isolates operative or procedural area from unsterile environment
- maintains sterile field for surgery or procedural intervention
sterile technique includes …
creating a sterile field and utilizing sterile objects to eliminate all microorganisms from an object or area
what is sterility?
the absence of viable life that has the potential to reproduce and spread dangerous and disease-causing germs and bacteria
if an object or area is touched by any object that is not sterile, it is considered?
contaminated
where is sterile technique most commonly utilized?
in the operating room
sterile technique should be used when performing any procedure that could …
introduce microbes into a pt
how do you know when to use sterile technique for a procedure?
the health care provider will place an order for it
sterile sites include
- organs (heart, brain, gallbladder, kidneys, pancreas, ovaries, nodes, spleen, liver)
- central vascular system (central or arterial line)
- bone or bone marrow
- cerebrospinal fluid
- pericardial fluid
- peritoneal fluid
- pleural fluid
- joint fluid
what is not a sterile site?
passageways that are open to the outside
ex: nasal passage, throat, sputum, esophogus/stomach, rectum, vagina, skin, local soft tissue infections, adscesses
a sterile object remains sterile only when touched by another sterile object. This principle guides a nurse in placement of sterile objects and how to handle them.
- sterile touching sterile remains sterile (e.g., use sterile gloves or sterile forceps to handle objects on a sterile field).
- sterile touching clean becomes contaminated (e.g., if the tip of a syringe or other sterile object touches the surface of a clean disposable glove, the object is contaminated).
- sterile touching contaminated becomes contaminated (e.g., when a nurse touches a sterile object with an ungloved hand, the object is contaminated).
- sterile state is questionable (e.g., when you find a tear or break in the covering of a sterile object). Discard it regardless of whether the object itself appears untouched.
only sterile objects may be places on a sterile field
- all items are properly sterilized before use.
- sterile objects are kept in clean, dry storage areas.
- the package or container holding a sterile object must be intact and dry. A package that is torn, punctured, wet, or open is considered unsterile. the outside of the package is not considered sterile
a sterile object or field out of the range of vision or an object held below a person’s waist is contaminated
- nurses never turn their back on a sterile field or tray or leave it unattended.
- contamination can occur accidentally by a dangling piece of clothing or an unknowing patient touching a sterile object.
- any object held below waist level is considered contaminated because it cannot always be viewed.
- keep sterile objects in front with the hands as close together as possible.
the edges of a sterile field or container are considered to be contaminated
- frequently you place sterile objects on a sterile towel, drape, or tray
- because the edge of the drape touches an unsterile surface such as a table or bed linen, a 2.5-cm (1-inch) border around the drape is considered contaminated.
- objects placed on the sterile field need to be inside this border.
- the edges of sterile containers become exposed to air after they are open and thus are contaminated.
preparing a sterile field
- you prepare the field by using the inner surface of a sterile wrapper as the work surface or by using a sterile drape or dressing tray.
- after creating the surface for the sterile field, add sterile items by placing them directly on the field or transferring them with sterile forceps. discard an object that comes in contact with the 2.5-cm (1-inch) border.
- sometimes you will wear sterile gloves while preparing items on a sterile field. If you do this, you can touch all items within your sterile field. if items being added to the sterile field are not within the kit, the gloves cannot touch the wrappers of sterile items
- items must be handed over by an assistant.
opening sterile kit
- wash hands before opening
- open outermost flap away from your body
- grab very end of the corner to open
- open side flap
- repeat with next side flap
- grab end of the innermost flap and take a step back while allowing the flap to fall
- any areas hanging off are not sterile
applying sterile gloves
- pick up gloves from inside sterile kit
- open gloves at the end of bed to avoid contaminating the sterile kit but DO NOT turn your back to the sterile field
____elimination is a basic human function
urinary
what is the nurses role in urinary elimination
assess the pt’s urinary tract functions and provide support for bladder emptying
kidneys
filtering blood through nephrons to make urine plus many other functions
ureters
transport urine from the kidneys to the bladder
bladder
reservoir for urine until the urge to urinate develops
urethra
where urine exits the body
kidney function
- formation of urine
- excretion or conservation of water
- electrolyte balance
- acid base balance
- excrete end products of metabolism
- activation of vitamin D
- production of erythropoietin
- production of renin
- excrete bacterial toxins, water soluble drugs, and drug metabolites
- regulate blood pressure via RAAS
what is the length of a female urethra?
3 to 4 cm
what is the length of a male urethra?
18 to 20 cm
act of urination
- brain structures influence bladder function
voiding
bladder contraction + urethral sphincter and pelvic floor muscle relaxation
- Stretching of bladder wall signals the micturition center in the sacral spinal cord.
- Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.
- When a person is ready to void, the external sphincter relaxes, the micturition reflex stimulates the detrusor muscle to contract, and the bladder empties.
common urinary elimination problems
- urinary retention
- UTI
- urinary incontinence
- urinary diversions (nephrostomy or urostomy)
UTI’s
- invasion of urinary tract by bacteria
- women are at greater risk for developing them
causes of UTI’s
- stasis of urine in bladder
- contamination in perineal/urethral area
- instrumentation
- reflux of urine
- previous UTI’s
cystitis (lower UTI)
- bladder and urethra affected SXS - suprapubic tenderness - dysuria - urgency - frequency - incontinence - foul smelling cloudy urine
pyelonephritis (upper UTI)
- kidneys affected along with bladder and urethra SXS - those of a lower UTI - CVA tenderness - fever - chills
nursing care for UTI’s
- monitor symptoms
- monitor I & O
- pain control
- keep area clean
- encourage fluids
- education
- medications
- preventions
urinary incontinence
involuntary leakage of urine
stress incontinence
involuntary urine loss from increasing abdominal pressure, coughing, sneezing, laughing, and physical activities
urge incontinence
- involuntary urine loss with abrupt strong desire to void, unable to make it to the bathroom in time
- more common in older adults
functional incontinence
- incontinence due to inability to get to the bathroom; physical limitations, loss of memory, disorientation
- these individuals are usually dependent on others
