Week 3 - Aseptic non-touch technique and wound assessment Flashcards
Clean Technique
- Visibly free from marks and stains
- is the removal of visible contamination or debris
Aseptic Technique
- Aims to prevent pathogenic microorganisms, in sufficient quantity to
cause infection from being introduced to susceptible sites by hands,
surfaces or equipment - To avoid contamination sterile single-use equipment or instruments must
be used according to manufacturer’s instructions. - There are two types, Standard and Surgical aseptic technique
Sterile Technique:
- is the complete absence of microorganisms for example during invasive
procedures and surgeries - It involves the use of sterile equipment and PPE
Standard ANTT
- < 20 minutes procedure
- Few & Small Key
Parts and Key Sites - Simple Wound, IMI, IV
Therapy
Surgical ANTT
- > 20 minutes procedure
- Large / Open Key Sites or
Multiple Key Parts - Complex Procedures/
Wounds, Surgery
key parts standard ANTT
- key parts are protected individually with micro critical aseptic fields
- non-touch technique is mandatory
- no gloves or non sterile gloves
key parts surgical ANTT
- key parts are protected collectively on a critical ascetic file (sterile drape)
- sterile gloves are essential
- non touch technique is decibel where possible
What is a key site
Any breaches in skin integrity
which could be a portal of entry for microorganisms to colonise the patient.
Includes wounds, IMI or IV sites.
What is a key part
Any parts of the equipment which come into contact with procedural equipment or the patient.
Includes needles, forceps, sterile
gauze to clean a wound.
What to consider with environmental management
➢Is it an appropriate time to do
a dressing? Cleaning? Busy?
➢ What is the air flow like?
➢ Is the environment dirty or
dusty?
➢ Is there sufficient space
around the bed? Close the
curtains.
➢ Has the wound trolley been
cleaned effectively?
Things to consider with glove use
- Non sterile gloves should be used when removing any
dressings as there is a risk of body fluid exposure - Hand hygiene should be performed when donning and
doffing of gloves - The use of non sterile gloves is not required within
Standard ANTT as once the dressing as removed, you will
be using your key parts of the tips of the forceps to cleanse
and dress the wound - However, please follow local policy regarding glove use in
the clinical environment.
Principles and Practices of
Aseptic Non-Touch Technique
Use only sterile equipment.
* A sterile field/object becomes contaminated when touched
by unsterile equipment.
* Take care when opening the dressing pack.
* The edges of the aseptic field are considered contaminated.
* Items held below the waist level are considered
contaminated.
* Clean/gloved hands should be kept in front with the hands
as close together as possible.
* Never turn your back on the aseptic field or leave the tray
unattended.
What to use field forceps for
Use the field forceps to transfer ‘key parts’
from the general aseptic field
What to use your working forceps for
Use the working forceps when working at the
‘key site’ (wound).
What is a wound
Any break in the skin can be classified as a wound.
What is a pimary intention wound
- intentional
Tissue surfaces have been approximated;
there is no or minimal tissue loss, includes: - Superficial Wounds
- Closed Surgical Incisions
- Wounds Joined by Adhesive ‘Glue
Healing Process is Predictable - Healing Time 4 -14 days
- Minimal Scarring
What is secondary intention wounds
- unintentional
Greater tissue damage, loss - Edges not easily approximated
- Delayed healing time
- Scarring
- More chance of complications
such as infection - Pressure injury, traumatic injury, burns,
dehisced surgical wounds
What is a tertiary intention wound
Wounds that are left open for 3-5 days to allow fluids or
infection to drain
* Are then closed with sutures, staples or adhesive skin
closures
What are the 3 phases of wound healing?
- haemostasis and inflammatory phase
- proliferative phase
- maturation and remodelling phase
What is the inflammatory phase
Starts immediately after injury &
lasts 3-6 days.
* Removes debris & prepares for new tissue:
o Haemostasis
(cessation of bleeding)
o Blood supply increases
(oxygen, nutrients, macrophages)
o Phagocytosis
(engulf microorganisms & cellular debris)
what is an acute wound?
- Primary intention or
secondary intention - <4 week
what is a chronic wound
Secondary intention
* Normal healing disrupted
* >4 weeks
What are the clinical observations during this inflmmatory phase?
- Pain
- Redness
- Swelling
- Heat
- Exudate (clear)
What is the proliferative phase?
Second phase; from day 3 to day 21 post injury.
* Laying down of new cells, connective tissue:
o Fibroblasts synthesize collagen (adding strength) & deposit fibrin
o Capillary formation & increased blood supply
What are the proliferative clinical observations during this phase
granulation tissue
Angiogenesis
epithelialisation
clinical observation of epithelialisation
Wound paler, tissue is thin, pink
clinical observation of granulation
Wound appears beefy, red, moist
clinical observation of Angiogenesis
Fragile tissue that bleeds easily
What is a maturation phase
Occurs from around day 21 up to 1-2 years after the injury.
* Strengthening and reorganising collagen fibres:
* New tissue continues to grow and develop
* Normal blood supply recreated
* Scar formation and wound contraction
clinical observation of the maturation phase
Scar appears smaller, flatter and paler
terms to describe surround skin (periwound) and wound edge
Dry and Flakey
* Oedema
* Blistered
* Bruised
* Fragile
* Calloused
* Wound Edge
- normal, rolled,
- ‘punched out’, raised
* Macerated
* Undermining
what consider with wound size
- Length
- Width
- Depth
If Applicable - Pressure Injury Stage
- Skin Tear Category
What are Granulating Tissue
Characteristics
- Ruddy (reddish)
- Beefy, bumpy, lumpy,
- Firm (attached)
- Pebbled (whitish spots)
- Moist
- Shiny
- Fragile
What are Epithelialising Tissue
Characteristics
Pinkish,
Tissue is thin, shiny,
translucent
What are slough tissue characteristics
- Comprised of multiple
elements - Waste, Fibrin, white blood cells
- Firmly attached or loose
- ‘chicken fat’
- Creamy/yellow
- Slimy, stringy, clumpy,
gelatinous, fibrous - Moist
- Thick & sticky (viscous)
- Slows healing; potential site
for microorganism g
What are necrotic tissue characteristics
- Dead tissue
- Adheres firmly to wound
- Hard and leathery OR soft & wet
- Black, brown, tan
- Slows healing; potential site for
microorganism proliferation - Full thickness tissue destruction
➢ Eschar – dry, dark scab of dead tissue
ISTAP skin tear classification type 1: NO skin loss
linear or flap tear which can be repositioned to cover the wound bed
What are sound characteristics of an infected wound
-Persistent redness, swelling,
pain
-Viscous discharge,
- yellowish/green
-Malodorous
ISTAP skin tear classification Type 2: PARTIAL flap loss
Partial flap loss, which cannot be repositioned to cover the wound bed
ISTAP skin tear classification type 3: TOTAL flap loss
total flap loss exposing the entire wound bed
What to consider when assessing exudate
- type
- amount
- colour
- odour
What are the different types of exudate
- serous
haemoserous/ serosanguinous - sanguineous/ haemorrhagic
- purulent
