WEEK 2: Asepsis and Dressings

Question 1

surgical asepsis

Answer 1

procedures to eliminate all microorganisms, including spores from an object/area

Question 2

principles of surgical asepsis

Answer 2

1 ) a sterile object only remains sterile when touched by another sterile object
- sterile object that touches a clean object = contaminated
- sterile object that touches contaminated object = contaminated
- sterile object that touches questionable object = contaminated
2 ) only sterile objects can be placed in the sterile field
3 ) a sterile object or field out of range of vision or an object held below the waist is contaminated
4 ) a sterile object or field becomes contaminated with prolonged exposure to air
5 ) wet/moisture = contaminated via capillary action
6 ) fluid flows with the direction of gravity
7 ) edges of a sterile field or container are considered contaminated

Question 3

Braden Scale

Answer 3

15-16, mild risk
13-14, moderate risk
10-12, high risk
<10, very high risk

Question 4

Staging Pressure Injury
stage 1

Answer 4

intact skin
nonblanchable erythema
changes in sensation, temperature, or firmness

Question 5

Staging Pressure Injury
stage 2

Answer 5

partial-thickness loss of skin with exposed dermis
the wound bed is viable, pink or red, and moist
- may present as an intact or ruptured serum-filled blister

Question 6

Staging Pressure Injury
stage 3

Answer 6

full-thickness loss of skin
adipose is visible
granulation tissue and epibole are often present
slough, eschar, or both may be visible
undermining and tunneling may occur

Question 7

Staging Pressure Injury
stage 4

Answer 7

full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone
slough, eschar, or both may be visible
epibole, undermining, tunneling, or a combination of these often occur

Question 8

Staging Pressure Injury
unstageable

Answer 8

full-thickness skin and tissue loss cannot be confirmed due to slough and eschar obscuring view
slough removed +stage 3 or 4 pressure injury revealed

Question 9

principles of wound care

Answer 9

1 ) protect wound
2 ) manage exudate
3 ) maintain moist environment
4 ) identify & treat infection
5 ) remove slough & necrotic tissue

Question 10

serous

Answer 10

clear, watery plasma

Question 11

purulent

Answer 11

thick, yellow, green, tan, or brown

Question 12

serosanguineous

Answer 12

pale, red, watery
mixture of clear and red fluid

Question 13

sanguineous

Answer 13

bright red
indicates active bleeding

Question 14

hemorrhage

Answer 14

bleeding from a wound site

Question 15

hematoma

Answer 15

localization of blood underneath the tissues
- appears as swelling, a change in color, sensation, or warmth, or a mass that often takes on a bluish discoloration

Question 16

infection

Answer 16

bacterial infection inhibits wound healing
- fever, tenderness, pain at the wound site
- elevated WBC

Question 17

dehiscence

Answer 17

the partial or total separation of wound layers

Question 18

evisceration

Answer 18

protrusion of visceral organs through a wound opening

Question 19

fistula

Answer 19

abnormal passage between 2 organs or between an organ and the outside of the body

Question 20

dry dressing

Answer 20

1 ) preform HH, apply sterile gloves
2 ) inspect wound for appearance, drains, drainage, and integrity
3 ) clean wound with solution
- use body temp solution when possible
- clean from least contaminated to most
4 ) gently pat peri wound area dry
5 ) apply appropriate type of dressing to cover the wound
6 ) apply topper (cover) dressing if required

Question 21

purpose of a dressing
7

Answer 21

1 ) Provides a moist environment for the wound bed
2 ) Protects patient from seeing the wound (if perceived as unpleasant).
3 ) Promotes thermal insulation of the wound surface.
4 ) Absorbs drainage and supports auto-lytic debridement.
5 ) Physically supports the wound site.
6 ) Aids in hemostasis.
7 ) Protects wound from microorganism contamination.

Question 22

wound healing
inflammatory phase duration

Answer 22

3 days

Question 23

wound healing
proliferation phase duration

Answer 23

3-24 days

Question 24

wound healing
remodeling phase duration

Answer 24

maturation
can take up to 2 years to heal
- depends on wound extent

Question 25

secondary intention

Answer 25

in this type of wound healing there is loss of tissue which must be filled with scar tissue
- chance of infection is greater

Question 26

primary intention

Answer 26

the skin edges are approximated or closed and the risk of infection is low
- there is little tissue repair required