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1008 Acute Care Nursing practice > Wound care and Aseptic > Flashcards

Wound care and Aseptic Flashcards

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1
Q

Three zones of the operating theatre?

A
  1. outer zone
    • main access corridor, transfer area, documentation area and patient holding area
  2. clean/semi restricted zone
    • clean corridor, sterile equipment, storage and anaesthesia/recovery
  3. restricted zone
    • scrub sinks and operating room
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2
Q

aseptic technique

A

= Aseptic technique is a process or procedure used to achieve asepsis to prevent the transfer of potentially pathogenic micro-organisms to a susceptible site that may result in the development of infection

  • Refers to knowledge and application of skills required when developing and maintaining a sterile field using aseptic technique
    • Area immediately surrounding the draped patient
    • Sterile surgical personnel
    • Sterile draped instrument tables and equipment
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3
Q

Surgical handwash

  • technique
  • duration
  • drying
  • what needed
A

Technique
• Remove jewellery
• Keep fingernails short
• Inspect skin for intactness
• Wash hands, nails & forearms thoroughly & apply a TGA approved hand disinfectant &/or antiseptic
• Rinse carefully, keeping hands above elbows
• No touch techniques apply

Durration

  • first wash of the day = 5 mins
  • subsequent was = 3 mins

Drying - with sterile towels

When needed - before any invasive surgical procedure

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4
Q

Three layers of the skin?

A
  1. epidermis
  2. dermis
  3. subcutis
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5
Q

Epidermis layer

A

• Epidermis, is the outer most layer, mainly consisting of keratinocytes, is continuously produced by the basal cell layer - a zone between dermis and epidermis.

  • The new epidermal cells (keratinocytes) rising to the surface of the skin, become loaded with keratin and are eliminated by desquamation after 8-10 days.
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6
Q

Dermis layer

A

• Thickest tissue layer of the skin
• Dermal thickness ranges from 2-4 mm
• Major proteins found in the dermis are collagen and elastin
- Other cells found in the dermis are mast cells, macrophages and lymphocytes
•Beneath the dermis is the hypodermis or subcutaneous fatty tissue

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7
Q

Subcutis layer

A

• Layer of adipose tissue or fat that:

  • attaches the dermis to the underlying muscles and bone
  • delivers the blood supply to the dermis, provides insulation and has a cushioning effect
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8
Q

Function of the skin

A 
Skin as a barrier protects against 
    o	Chemical and mechanical damage
    o	Bacterial and viral pathogens
    o	Ultraviolet radiation 
    o	Also prevents excessive loss of fluids and electrolytes to maintain the homeostatic environment
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9
Q

Factors affecting the bodys ability to maintain intact and healthy skin

A

o Wounds are disruptions that may occur in the skin’s integrity, leading to a loss of the skins normal functioning

o Factors that lead to the development of wounds and delays in wound healing include vascular disease, diabetes, malnutrition, medications, excessive moisture, external forces and the aging process

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10
Q

what is a wound

A

= a break in the epidermis of the skin that can lead to infection and sepsis

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11
Q

Types of wounds

A
  • acute

- chronic

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12
Q

Chronic wounds

A
  • Arterial and venous leg ulcers
  • Pressure ulcers
  • Neuropathic ulcers
  • Malignant ulcers
  • Chronic wounds are in principle acute wounds where the healing process has stopped or has been interrupted somewhere in the normal sequence
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13
Q

Acute wounds

A
  • Burns
  • Donor sites
  • Aberrations - Traumatic abrasions are caused by a moving surface rubbing against the skin or by dragging along a rough surface
  • Incisional/surgical wounds
  • Trauma
  • An acute wound occurs when healthy tissue is damaged by traumatic means, such as surgery, heat, electricity, chemical or abrasions
  • The continuity of the skin surface loss
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14
Q

Types of wound healing

A

Primary = Clean, straight line, edges well approximated with sutures, rapid healing

Secondary = Larger wounds with tissue loss, edges not approximated, heals from the inside out, granulation tissue fills in the wound, longer healing time, larger scars

Tertiary = Delay 3-5 days before injury is sutured, greater access from pathogens to invade, greater inflammation, more granulation, larger scars

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15
Q

Phases of wound healing (4)

A
  1. immediate = haemostasis
  2. inflammation phase - increased blood flow
    • debridement (phagocytosis
    • removal of cellular debris/devitalised tissue and cleaning of wound
    • macrophages adn leukocytes are dominating cells
    • 2-3 days
  3. proliferation
    • macrophages attract endothelial cells
    • new capillaries are formed
    • fibroblast amount increase
      - collagen produced
      - granulation - red appearance
      - epithelialisation
  4. maturation
    - transformation of the produced collagen will increase the strength of the connective tissue
    - some of the capillaries formed during granulation will disappear thereby normalising the blood supply
    - duration - longer than a year
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16
Q

Surgical wound healing

A
  • Wounds that heal by primary intervention should be left covered for the first 48 hours and will normally seal and dry out within this period
  • These wounds will usually heal within eight to 14days depending on the type of surgery
  • Healing should coincide with the removal of clips or staples
17
Q

Surgical wound types

A
  1. clean
    • Elective, not emergency, non-traumatic, primarily closed
    • No acute inflammation
    • No break-in technique
    • Respiratory, gastrointestinal, biliary and genitourinary tracts not entered
  2. clean- contaminated
    • Urgent or emergency case that is otherwise clean
    • Elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage not encountering infected urine or bile
    • Minor technique break
  3. contaminated
    • Non-purulent inflammation
    • Gross spillage from gastrointestinal tract: entry into binary or genitourinary tract in the presence of infected bile or urine
    • Major break-in technique
    • Penetrating trauma < 4 hours old
    • Chronic open wounds to be grafted or covered
  4. dirty
    - Purulent inflammation (e.g. abscess)
    • Pre-operative perforation of respiratory, gastrointestinal, biliary or genitourinary tract
    • Penetrating trauma
    >4 hours old
18
Q

Principles of wound management?

A

Examination/ assessment
- wound appearance (colour, depth, position, pain and exudate) surround skin

History
- diet, smoking, medications, issues, surgeries

investigations

19
Q

4 stages of wound management?

A
  1. define the aetiology
  2. identify and control factors affecting wound healing
  3. select the appropriate wound dressing
  4. maintain wound healing
20
Q

Wound management : defining aetiology

A
  • Vascular: chronic venous insufficiency arterial mixed vasculitis
  • Mechanical: pressure, friction, shear, trauma, neuropathic, surgical infection
21
Q

Wound management: Control factors inhibiting the healing process

A
  • health status
  • age
  • body build/obesity
  • immune function
  • poor nutritional status
  • peripheral vascular disease (atherosclerosis)
  • diabetes
22
Q

Wound management: local factors that can affect healing extrinsic

A
  • drying/maceration
  • wound temp
  • mechanical stress; pressure, friction and shearing force
  • chemical stress
  • foreign bodies
  • infection
23
Q

Wound management: principles of wound healing (maintain wound healing)

A
  • moisture
  • exudate control
  • temp control
  • infection free
  • controlling inflammation
  • nutrition
  • wound dressing clean
24
Q

infection diagnostic criteria:

A
  • abscess
  • cellulitis
  • discharge
  • delayed healing
  • discolouration
  • bleeding granulation tissue
  • unexpected pain, tenderness, erythema
  • abnormal smell, wound breakdown
25
Q

preventing surgical site infection

A

Pre-operative prevention
• Length of preoperative stay (patients being admitted for planned elective surgery should be admitted as close to the date of surgery as
• possible to reduce the risk of infection)
• Optimal hand hygiene
• Prophylactic antibiotics should always be given for clean-contaminated, contaminated and dirty/infected wounds. They should be administered

26
Q

Preoperative prevention of infection

A
  • hand hygiene
  • appropriate theatre wear
  • skin preparation
  • wound irrigation
  • wound closure techniques
  • glucose control
27
Q

Post operative prevention of infection

A
  • HH
  • use of drains
  • use of interactive dressings
  • recognition of infection and appropriate use of antibiotics
  • education pt
28
Q

Wound dehiscence?

A

= partial or total separation of previously approximated wound edges, due to a failure of proper wound healing

29
Q

Causes of wound dehiscence?

A
  • Infection
  • A failure to achieve haemostasis with subsequent haematoma development
  • Poor nutritional intake
  • Excessive exudate caused by an infection or localised oedema
  • Poor quality vascular supply caused by a chronic or acute medical condition, an emboli, oedema, anaemia, obesity or smoking
30
Q

Wound assessment

A
  • Wound etiology
  • Pain and odour assessment
  • Wound site/anatomical location
  • Would bed and surrounding skin appearance
  • Measurement of wound depth and undermining
  • Rationale for dressing regime
31
Q

Classifications of wounds

A

Red - yellow - black

Red = mainly red granulation tissue

yellow = Covered with sloughy material consisting of necrotic tissue and fibrin it remains yellow, brown or grey while it is moist
• It may be adherent to the wound bed or edges or loosely adherent and stringy

Black = covered with necrotic tissue

32
Q

Wound exudate

A

= ecaudate is an accumulation of fluids in the wound, may contain serum, cellular debris, bacteria and leukocytes

33
Q

types of wound exudate

A

• Serous-clear, watery plasma

  • Sanguineous/haemorrhagic-indicates fresh bleeding
  • Serosanguineous/haemoserous-mixture of serous and sanguineous
  • Purulent-thick yellow, green or brown fluid indicative of infection
34
Q

Aseptic non touch technique (ANTT)

A
  • Aseptic technique: aims to prevent pathogenic organisms in sufficient quality to cause infection from being introduced to susceptible sites by hands, surfaces and equipment
  • Non-touch technique: not touching key parts directly or indirectly

surgical hand was = 2 % and 60 secs

35
Q

Compare Moist healing Vs Dry healing

A

Moist - wound healing is twice as fast as dry wound healing

 * By keeping the wound moist you provide optimal environment for the body's own wound healing system 
 * Prevents the formation of scab
 * Provides optimal conditions for the body’s own would healing system 
 * Speeds up healing process
 * Saves time, money and suffering

Dry healing

  • drying out the wound
  • scab form
  • mechanical injury to the granulating tissue
  • longer healing time

1008 Acute Care Nursing practice (10 decks)

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