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N1213 > Wound Care > Flashcards

Wound Care Flashcards

1
Q

What are situations that require surgical asepsis?

A

1) intentional perforation of client’s skin (e.g. insertion of intravenous catheters or administration of injections)
2) skin’s integrity is broken as a result of trauma, surgical incision, or burns
3) insertion of catheters or surgical instruments into sterile body cavities

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2
Q

List three (3) teaching principles to prevent client contamination of procedures?

A

1) avoid sudden movements of body parts covered by sterile drapes
2) avoid touching sterile supplies, drapes, or the nurse’s gloves and gown
3) avoid coughing, sneezing, or talking over a sterile area

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3
Q

Provide nursing interventions for each of the client’s anticipated issues during a prolonged sterile procedure.

A) Pain

A

A) administer analgesic <30 min before procedure

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4
Q

Provide nursing interventions for each of the client’s anticipated issues during a prolonged sterile procedure.

B) Voiding

A

B) take them to pee before

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5
Q

Provide nursing interventions for each of the client’s anticipated issues during a prolonged sterile procedure.

C) Comfort

A

C) assume most comfortable position before

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6
Q

Provide nursing interventions for each of the client’s anticipated issues during a prolonged sterile procedure.

D) Sneezing

A

D) need to cough: offer patient a mask if you anticipate he has a respiratory problem

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7
Q

Nosocomial infection

A
  • an infection acquired in a hospital, nursing home, or other health care settings. Burn patients have highest rates of nosocomial infections
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8
Q

Sterilization

A
  • process of completely removing or destroying all microorganisms from an object
  • includes bacterial spores
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9
Q
  • work area which is free of any contamination, where sterile water and tools are placed to protect them from possibilities of contamination from surround environments
A

Sterile field

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10
Q

A new infection caused by an organism different from that which caused the initial infection. Caused by a microbe that is resistant to the treatment given for initial infection.

A

superinfection

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11
Q

The application of a disinfectant to materials and surfaces to destroy pathogenic microorganisms.
Not including bacterial spores

A

Disinfection

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12
Q

Invasive

A

Tending to spread. (e.g. The tendency of a malignant process or growth to spread into healthy tissue.)

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13
Q

A living organism too small to be perceived with the naked eye. (e.g. virus, bacterium, fungus, intracellular parasite. Etc)

A

Microorganism

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14
Q

List seven (7) purposes for wound dressings:

A

I. Protects from microorganism contamination
II. hemostasis
III. Promotes healing
IV. Supports or splints the wound site
V. Protects the client form seeing the wound
VI. Promotes thermal insulation
VII. Provides a moist environment

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15
Q

When are wound dressings no longer required?

A

When surgical wounds heal by primary intervention, it is common to remove dressings as soon as drainage stops.

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16
Q

Primary layer/contact layer

A
  • covers the incision and part of the adjacent skin.

- blood products and debris adhere to the dressing’s surface.

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17
Q

Absorbent layer

A
  • This layer absorbs any seepage or weeping of wound fluids, thus preventing spread of unwanted body fluids outside of the dressing area.
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18
Q

Outer protective (secondary) layer:

A
  • Helps prevent contamination from external sources. (e.g. feces or urine)
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19
Q

Provide a rationale for when applying a drain dressing; use 2 split gauze dressings, facing in opposite directions.

A

Rational:

  • The gauze needs to be moist
  • least amount of irritation to the wound, as well as prevention of any tearing.
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20
Q

When applying a drain dressing, place the drain gauze on top of the contact layer of the incision dressing.

A

prevents strikethrough of wound drainage and provides a surface to tape the dressing in place

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21
Q

What would you do if you saw Serosaguinous drainage of the outer layer of the dressing within the first 48 hours?

A
  • serosaguinous: containing, or of the nature of serum and blood.
    • Observe wound for increased drainage or separation of sutures.
    • Instruct client to lie still.
    • Notify health care professional.
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22
Q

What do you do if the entire dressing becomes saturated with blood?

A
  • Observe colour. If drainage is bright red and excessive, you will need to apply pressure.
  • Inspect along dressing and underneath client to determine amount of bleeding.
  • Obtain vital signs, as needed.
  • Notify health care professional.
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23
Q

What is an abdominal binder?

A

bandage applied over or around dressings = extra protection and therapeutic benefits.

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24
Q

What are benefits of an abdominal binder (6)?

A 
o Create pressure
o Immobilizing body part
o Supporting wound
o Prevent edema
o Securing a splint
o Securing dressings
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25
Q

What are the 3 assessment parameters to be completed before applying a binder?

A
  1. Assessing the condition of underlying dressings and change them, if soiled.
  2. Assessing the skin of underlying areas
  3. Inspecting the skin for abrasions, edema, discolouration, or exposed wound edges.
26
Q

A sterile object remains sterile only when touched by another sterile object

A

Contamination: touching a clean glove with the tip of a syringe, or if packaging is torn

27
Q

Only sterile objects may be placed on the sterile field

A

Contamination: package is torn, punctured, wet, or open is considered contaminated

28
Q

Sterile objects can become unsterile by prolonged/excessive exposure to airborne microorganisms.

A
  • No one should talk, laugh, sneeze or cough over a sterile field, or when gathering sterile equipment.
  • Excessive movements or rearranging of linen after sterile packages have been opened.
  • When there is excessive movements of staff around the sterile filed after packages have been opened.
29
Q

A sterile object or field out of the range of vision (i.e below the waist) is considered to be contaminated.

A
  • Dangling piece of clothing
  • Falling hair
  • Equipment held below the waist line
  • Unknowing client touching a sterile object.
30
Q

Fluid flows In the direction of gravity.

A

• Gravity causes a contaminated liquid to flow over the object’s surface.
- Improper drying of hands, (below elbows).

31
Q

Moisture draws in microorganisms from unsterile surfaces to the sterile object/sterile surfaces by capillary action.

A
  • Any spill can be a source of contamination (i.e. when poring sterile solutions).
  • When stored sterile packages become wet.
32
Q

One inch (2.5 cm) around the edge of a sterile field, the edges of dressing trays and the lip of a previously opened liquid are considered to be unsterile.

A

• 2.5 cm distance from the edge of the sterile field is considered contaminated.
• Edges of sterile containers exposed to air after they are opened.
- A lip of a bottle of solution becomes contaminated after it is exposed to air

33
Q

List some of the steps for opening a sterile package (6)?

A
  1. Hold package firmly in your dominant hand, well above waist level.
  2. Use the same sequence to open the flaps of the package, opening the first flap away from your hand.
  3. Allow the towel edges to fall away from your hand.
  4. Grasp the edges of the wrapper, pulling them towards your forearm.
  5. Gently drop the contents onto your sterile field
    OR
  6. Pass the contents off to your colleague.
34
Q

You are collecting supplies for your client’s dressing change and notice the open box of 4x4’s are beside the sink. You label them contaminated and open another box.

A
  • Factors that contribute to the possible contamination of opened box include the exposure to air.
  • The exposure of an open box beside the sink, which is in contact with a wet contaminated surface.
35
Q

To open a sterile dressing tray, you open the first flap away from you, ensuring your arm does not pass over the field.

A

• It is important to minimize the movement of air around the sterile field. Microorganisms travel on droplets through the air.
Microorganisms traveling through the air ca fall on sterile items or fields by reaching over the work area.

36
Q

You continue with your dressing after sterile water drips onto your drape when you wet your 2x2.

A

Fluid flows in the direction of gravity.
In terms of contamination, anything below the waist line is considered to be contaminated. Depending on where the sterile water drips onto your drape, the procedure would continue if drips are on lower drape, below the waistline.

37
Q

You ensure your hair is tied back securely when working with a sterile field.

A

• For sterile surgical procedures, you must apply a clan cap that covers all hair.
Purpose is to prevent hanging hair from coming into contact with a potentially contaminated/contaminated/ or sterile object or environment.

38
Q

You notice that your sterile scissors expired the day before, and send it back to be re-sterilized.

A
  • The use of an expired sterile object could potentially cause infection to patient, and but them at risk.
  • Many objects and packages have indicators as well as expiry dates printed on them. If the indicator is not the appropriate colour, but still within its expiry date, consider it contaminated.
39
Q

You draw the patient’s privacy curtain PRIOR to setting up your sterile field.

A

Patient’s privacy curtain is considered a contaminated object, or a potential contaminated object, and should be moved prier setting sterile environment. This way, you won’t contaminate your sterile environment or objects by touching the curtain after preparing sterile field.

40
Q

When completing a dressing, you avert your head from your sterile field if you need to speak to your patient.

A

By turning your head away from the sterile field, you prevent risk of contamination by spreading of air-born microorganisms, as well as transmitting possible microorganisms via moisture from your mouth/mask.

41
Q

Prior to pouring sterile saline into your dressing tray, you note that the bottle does not have a “date” written on it so you get a new one.

A

Not knowing “dates” puts your patient at risk. You should at NO POINT risk using equipment your not
Make sure that all equipment to be used during a sterile procedure is up to date, and packaged or handled properly.
- When pouring from a bottle, it is held with the label in the palm of your hand.

42
Q

You hold the bottle outside of the sterile field when pouring solutions in the tray.

A

Any spill can be source of contamination unless the object or field rests on a sterile surface that cannot be penetrated by moisture.

43
Q

When opening your fenestrated drape you use your green forceps if it is stuck rather than shaking it open.

A

• Shaking the fenestrated drape open could cause contamination by spreading microorganisms via air particles.
Green forceps are designed so that you may open drapes with minimal disturbance of the environment surrounding it.

44
Q

Wounds are cleansed with normal saline or another non-cytotoxic solution.

A

Cytotoxic solutions would prevent cell growth and repair of a wound site. It is rational to use a solution that helps prevent infection without halting the progress of healing.

45
Q

Never use the same piece of gauze to cleanse across an incision or wound twice

A

• Once a section of gauze comes into contact with a surface, which is otherwise sterile, it is considered contaminated.
Using the same piece of gauze multiple times increases the chances of spreading microorganisms, thus contaminating the incision or wound.

46
Q

Drains are cleansed after the incision, in an outwardly circular motion.

A

• Drain sites are a source of contamination because moist drainage harbors microorganisms.
• The skin near the site is more contaminated that the site itself.
The circular motion controls which way potential microorganisms are being removed. This prevents any possible microorganisms brushing over wound site.

47
Q

Under what circumstances does a nurse collect a culture of wound drainage?

A

• A culture/drainage helps to determine whether a wound has become infected,

48
Q

Is physician’s/nurse practitioner’s order required in order to send a culture for testing?

A

1) doctor suspects that a wound is infected.

2) treatment’s effectiveness

49
Q

Why do you need to apply pressure to a wound bed when obtaining a swab?

A

trigger seepage of pus and or other fluids

50
Q

After the swab is collected, what must the nurse do to start the process of growing the organism?

A
  • placed in appropriate nutrient media’s

* air for growth (aerobic) while some require a no-oxygen or reduced-oxygen environment (anaerobic or microaerophilic).

51
Q

Intermittent sutures

A

cut the suture as close to the skin as possible, away from the knot. Never pull contaminated stitch
through the tissues

  • surgeon ties each individual suture made in skin
52
Q

Continuous Sutures

A

only 2 knots. Do not pull visible sutures under the skin, because they harbour bacteria

53
Q

Retention Sutures

A

nurses may or may not remove these (according to policy)

  • placed more deeply
54
Q

Moist Healing (pefered) (4)

A
  • dec. risk of infection
  • dec. healing time
  • faster repeithelization
  • better cosmetic
55
Q

Dry Healing (surgical dressing)

A
  • encourages scab formation
  • delays healing
  • inc. pain
  • may produce scar
56
Q

Post-op dressing change typically within ____ hrs

A

24-72

57
Q

Open bottles are sterile for ___ hrs

A

24

58
Q

The edges of a sterile field are considered ________ (1” border)

A

non-sterile

59
Q

Debridement

A
  • removal of non-viable, necrotic tissue
60
Q

Dressing change frequency

A
  • doctors order
  • physician/NP
  • Allied health wound team (OT/PT)
61
Q

What are general considerations for Suture/Staple Removal? (5)

A

• Check Physician/Nurse Practitioner order
• Limit amount of dressing supplies opened
• Never pull the contaminated, outer aspect of a stitch through (underneath) tissue.
• Notify physician immediately if inadequate wound healing or if dehiscence noted during or after suture/staple removal.
- Cleans suture/staple sites after removal

62
Q

Dressing change frequency

A
  • doctors order
  • physician/NP
  • Allied health wound team (OT/PT)

N1213 (9 decks)

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