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PN Exam 8 Class #89
Ch 22, 26, 34 NF Ch 12 MS
| Question | Answer |
|---|---|
| Which is the method used to prevent contamination during invasive procedures or procedures that involve entering body cavities? | Surgical Asepsis or The Steril Technique |
| What is Disinfection? | The process used to kill bloodborne pathogens and the growth of organisms that cause infection. |
| What is Sterilization? | Uses steam under pressure, gas, or radiation to kill all pathogens and their spores. |
| What are the 5 types of Sterilization? | 1. Autoclaving 2. Boiling 3. Ionizing Radiation 4. Chemical Disinfection 5. Gaseous Disinfection |
| What is a "Strike-Through"? | Indicator tape around a surgically sterilized equipment that has been visibly made wet, this is no longer considered sterile and cannot be used. |
| What are some indications of Sterility? | 1. double wrapped in surgical towel 2. indicator tape w. black marks 3. initials, date, and expiration date |
| What is Autoclaving? | Steam under pressure sterilization technique, heat ranges from 250-270 degrees. |
| What is Boiling? | Sterilization obtained by boiling instruments and supplies for 10 minutes: does not kill spores. |
| What is Ionizing Radiation? | This method of sterilization kills pathogens on sutures, some plastics, and biological materials that cannot be boiled or autoclaved. |
| What is Chemical Disinfection? | This method is used to kill pathogens on equipment and supplies that cannot be heated. Ex. Cidex |
| What is Gaseous Disinfection? | This method kills pathogens on supplies and equipment that are heat sensitive or must remain dry. |
| What are 2 common procedures that use surgical asepsis? | 1. Inserting urinary catheters 2. suctioning deep airways |
| What is a Sterile Conscience? | Always being aware of potential or certain contamination of the sterile field or sterile objects and taking appropriate steps to correct the situation. |
| What must you always consider above your own right to practice medically? | Be honest about a mistake or potential mistake and put the PATIENTS safety above your own well-being or convenience. |
| What is the Rule of Sterility? | Sterile + Sterile = Sterile Anything unsterile, no matter what it touches, is considered contaminated. |
| What are the general guidelines for opening up sterile packs for your sterile field? | 1. Set sterile pack on clean surface, with first flap opening away 2. Open pack AWAY from you, and the pack that is furthest from you first 3. Do not touch the inner wrapper ever |
| What are the Rules to uphold while working from a sterile field? | 1. Do not reach across the sterile field! 2. Keep the sterile field in eyes view AT ALL TIMES 3. Never turn your back on said sterile field 4. After sterile gloves are donned, keep them in THE SAFETY ZONE 5. Don't prepare the sterile field too early! |
| When may Non-sterile technique be used for some procedures that are usually sterile? | In the home care setting: specifically with reusable catheters for bladder drainage. |
| Should Sterile technique be used in the Nursing home or long-term care setting? | Yes, always if the procedure is appropriate. |
| Suffix -ectomy means? | Removal by cutting. |
| Suffix -orrhaphy means? | Suture or repair. |
| Suffix -oscopy means? | Looking into. |
| Suffix -ostomy means? | Formation of a permanent artificial opening. |
| Suffix -otomy means? | Incision or cutting into. |
| Suffix -plasty means? | Formation or repair. |
| Urgency level of Surgery: Emergency | Immediate surgery needed to save life or limb without delay. Ex. Ruptured aortic aneurysm or appendix, traumatic limb amputation, loss of extremity pulse from emboli. |
| Urgency level of Surgery: Urgent | Surgery needed within 24-30 hrs. Ex. Fracture repair, infected gallbladder. |
| Urgency level of Surgery: Elective | Planned/Scheduled, with no time requirements. Ex. Joint replacement, hernia repair, skin lesion removal. |
| Urgency level of Surgery: Optional | Surgery requested by the patient, Ex. Cosmetic Surgery. |
| Purpose of Surgery: Aesthetic | Requested by patient for improvement. Ex. Blepharoplasty, breast augmentation. |
| Purpose of Surgery: Diagnostic | To obtain tissue samples, make an incision, or use a scope to make a diagnosis. Ex. Biopsy |
| Purpose of Surgery: Exploratory | Confirmation or measurement of extent of condition. Ex. Exploratory laparotomy. |
| Purpose of Surgery: Preventative | Removal of tissue before it causes a problem. Ex. Mole or polyp removal to prevent cancer. |
| Purpose of Surgery: Curative | Removal of diseased or abnormal tissue. Ex. Inflamed appendix, tumor, benign cyst, hernia. |
| Purpose of Surgery: Reconstructive | Correction of defects of body parts. Ex. Scar repair, total knee replacement, face lift, mammoplasty. |
| Purpose of Surgery: Palliative | Alleviation of symptoms when disease cannot be cured. Ex. Debulking (tumor removal) to relieve pain or pressure, colostomy for incurable bowel obstruction, insert. of gastrostomy tube for swallowing probs, rhizotomy (cuts nerve to relieve pain). |
| What are the 3 Perioperative Surgical Phases? | 1.Preoperative: Decision for surgery - transfer to OR 2. Intraoperative: Transfer to OR - addmission to PACU 3. Postoperative: Admission to PACU - until recovery is complete |
| What is PACU? | Perianesthesia Care Unit |
| What are some of the steps to the Preadmission Surgical Patient Assessment? | 1. Interview with an Anesthesiologist 2. Preadmit interview with RN 3. Discussed health history/ issues **4. Urine or serum pregnancy test to rule out pregnancy 5. Asked if patient has an advanced directive |
| What is Malignant Hyperthermia? | A potentially life-threatening hereditary muscular disease, which can be triggered by some types of anesthesia. |
| If a patient has symptoms of Malignant Hyperthermia during surgery? | 1. Surgery is stopped 2. Anesthesia is discontinued immediately 3. Oxygen at 100% is given 4. Patient is cooled with ice and infusions of ice solutions **5. DANTROLENE SODIUM (Dantrium) muscle relaxant relieves the muscle spasms. |
| Pre-op teaching for common surgical routines includes? | 1. Date and time of admit and surgery 2. Admission (pre-op prep 2 hrs prior) 3. Length of stay, items to bring and wear 4. Recovery after surgery 5. Family Info 6. Discharge criteria |
| What are some common steps for Pre-op Preparation? | 1. Nasal Culture for strep A 2. Medications to take the morning of 3. Instructions for post-op care are given ahead 4. Post-op exercises are taught prior 5. Deep breathing exercises are taught (avoids atelectasis) 6. Incentive Spirometry may be used |
| When teaching Incentive Spirometry use, what should be included? | 1. Sit upright, @ 45 degree angle minimum if possible 2. Take in 2 normal breaths, place mouthpeice in mouth 3. Inhale until target level is reached, hold breath 3-5 secs 4. Exhale completely 5. Perform 10 sets of breaths as ordered |
| When teaching Coughing remember what? | 1. Give adequate pain medication before hand 2. Split incision with pillow if needed 3. Repeat several sets of coughs every 1-2 hrs when awake |
| How often should leg exercises and foot circles be done? | Every hour while awake unless contraindicated. They improve circulation and prevent emboli formation. |
| What is the easiest way for a patient to turn side to side in bed? | With their top leg bent. After, support legs with a pillow in between for positioning. Use side rail to help them, unless contraindicated, Deep breath while moving instead of holding their breath. |
| What can you do to assist a patient getting out of bed post-op? | Turn them on side without pillows, place hands flat on bed, push up while swinging legs out of bed to sit, dangle to prevent dizziness, deep breath while sitting. |
| What should be reviewed in medication history prior to surgery? | 1. All prescriptions and over the counter meds., Herbal remedies, anticoagulants, NSAID's. 2. Patients who take insulin for diabetes may need to decrease or stop taking insulin temporarily. **3. Patients on chronic oral steroid therapy cannot stop abruptl |
| Preoperative Med: Antiemetics | Control Nausea and Vomiting Examples: Metoclopramide (Reglan) Ondansetron (Zofran) Prochlorperazine (Compazine) Promethazine Hydrochloride (Phenergan) Nursing Imp: Redness burning or pain at site of injection, Increased drowsiness w. opioids |
| Preoperative Med: Antibiotics | Prevention of Post-op Infection Examples: Variety of Antibiotics used Nursing Imp: Give w/i 30-60mins of incision |
| Preoperative Med: Opioids | Bind to Opioid Receptors in CNS alter pain perception Examples: Fentanyl (Sublimaze) Hydromorphone Hydrochloride (Dilauded) Mepheridine (Demerol) Morphine Sulfate Nursing Imp: Monitor VS, level of sedation, Resp. status. |
| Discharge from the Parianesthesia Care Unit (PACU) length of stay for a stable patient is? | Usually 1hr. when the discharge criteria are met, the patient is usually discharged to a nursing unit or home. When discharge criteria are NOT met, the patient may be transferred to the ICU. |
| What safety interventions are used to help prevent falls post-op? | 1. Bed placed in lowest position, wheels locked, rails raised and call button within patient's reach 2. Instruct the patient to use call bell when wishing to ambulate 3. 1-2 health care workers will assist with transfer |
| What is the discharge criteria for Perianesthesia Care Unit or Ambulatory Surgery? | 1. VS stable, normal Temp 2. Patient awake or baseline consciousness 3. Drainage or bleeding not excessive 4. Resp. function not depressed 5. O2 Sat above 90% |
| What are some of the negative psychological effects of unrelieved pain? | 1. Impairs deep breathing and coughing 2. Early ambulation is more difficult 3. Increased complications, length of Hosp. stay, and health care costs can occur |
| Pain treated along various pathways provides what? | Better relief: lower doses of opioids, and use of Tylenol and NSAID's should be considered. It reduces patient suffering and promotes a quicker recovery. |
| When collecting data for pain, what should a nurse take into consideration? | 1. Monitor non-verbal indications of pain in patients who are not fully awake. 2. Ask patients who are awake about locations of pain, rate the presence, and describe pain quality. |
| What is an Incision? | A wound made by a surgeon with a sharp instrument such as a scalpel. |
| As a wound heals, when are sutures or staples removed? | In 7-10 days |
| What is a Clean wound? | Surgical wounds that are not infected. |
| What is a Dirty wound? | AKA Contaminated: Include accidental wounds or surgical incisions exposed to unsterile conditions. |
| What is Debridement? | When necrotic and infected tissue is removed before infected wounds are closed. |
| What are the 3 ways wounds heal? | 1. Primary Intention 2. Secondary Intention 3. Tertiary Intention |
| What are some wound complicaions? | Hematoma, Infection, dehiscence, and evisceration. |
| What are common signs of an infected wound? | Warm, reddened, or tender and have purulent drainage (pus). |
| What is wound Dihiscence? | The sudden bursting open of a wound's edges. May be preceded by an increase in serosanguineous drainage. Often occurs with abdominal incisions. |
| What is Evisceration? | When the viscera spill out of the abdomen. Often occurs with abdominal incisions. |
| If Evisceration occurs, the patient may say something along the lines of what? | "Something let loose" or "gave way". Often accompanied by pain and vomiting. |
| If Dehiscence or Evisceration occur what should you do? | Position the patient in the LOW Fowler's position with knees flexed. Cover the wound with STERILE dressings or clean towels moistened with Normal Saline. Notify the surgeon immediately. |
| Why are drains inserted into wounds during surgery? | To prevent accumulation of blood, lymph, or necrotic tissue in wounds that can lead to infection or delayed healing. |
| Drains may work by what 2 methods? | Gravity or Suction |
| What is Serosangiuuineous drainage?? | Moderate pink fluid. |
| What is Sanguineous drainage? | Red surgical wound drainage often seen just after initial operataion. When this type of fluid does not go away, it may be a sign of hemorrhage. |
| What is Serous drainage? | Pale yellow drainage that is excreted hours to days after surgery. |
| To help meet the energy needs of a post-op patient, what common supplements should be given? | Boost Breeze and Ensure Clear |
| What are some specific nutrients needed to promote healing in post-op patients? | 1. Vitamin C for collagen formation 2. Vitamin K for blood clotting 3. Zinc for tissue growth, skin integrity, and cell mediated immunity 4. Protein for controlling fluid balance and edema, antibody formation, white blood cell production, and building sca |
| What are the 2 Categories of wounds? | 1. Open- a wound in which the skin integrity has been breached 2. Closed- a wound in which the skin remains intact |
| What is a Contusion? | A closed discolored wound caused by blunt trauma, better known as a bruise. |
| What is an Abrasion? | A superficial open wound. Includes: scrapes, scratches, or rub-type wounds where the skin is broken. **Generally heal well if they are kept clean. |
| What is a Puncture wound? | An open wound that results when a sharp item, such as a needle, nail, or piece of wire, pierces the skin. |
| What is a Penetrating wound? | Similar to a puncture wound: the difference is that the offending object remains EMBEDDED in the tissue. |
| What is a Laceration? | An open wound made by the accidental cutting or tearing of tissue. |
| What is a Pressure Injury? | A wound resulting from pressure and friction. skin may be intact and erythemic (reddened), or the skin may be nonintact with open areas. |
| What are the 5 Categories of wounds? | **1. Clean **2. Clean-Contaminated 3. Contaminated 4. Infected 5. Colonized |
| What is the Difference between Clean and Clean-Contaminated wounds? | Clean wounds: A wound that is not infected Clean-Contaminated wounds: A wound that was surgically made and is not infected, but it has direct contact with the normal flora in either the respiratory tract, urinary tract, or gastrointestinal tract. |
| Risk Factors for Pressure Injuries are? | 1. Elderly 2. Emaciated or Malnourished 3. Incontinent of Bowel or Bladder 4. Immobile **5. Impaired Circulation or Chronic Metabolic Conditions |
| What are some Nursing Interventions to prevent Pressure Injuries? | 1. Reposition the patient at least every 2 hours 2. Keep skin clear and dry 3. Assess incontinence every hour |
| How do Stasis Ulcers Develop? | When venous blood flow is sluggish, generally in the lower extremities, allowing deoxygenated blood to pool in the veins. |
| What is a Sinus Tract? | A channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin, sometimes known as a fistula. |
| What is Granulation? | New healing tissue that is red and semi-transparent. It is extremely fragile. |
| What is the most common microbial pathogen associated with wound infections? | Staphylococcus Aureus (Staph A) |
| What does the bacteria Closridia in a wound lead to? | Gas Gangrene: which causes tissue to die while still being attached to living tissue. **must be treated with debridement and a hyperbaric chamber which delivers O2 to the tissue. |
| What should a nurse include in a wound assessment summary? | 1. Site: location 2. Wound Type: open or closed 3. Wound Closure: what was used 4. Size 5. Condition of wound bed 6. Condition of skin surrounding the wound 7. Pain 8. Drainage |
| What is the purpose of an Alginate dressing? | loosely packed or layered in wounds or sinus tracts to absorb drainage. Ex. Algisite, Curasorb, Kalogel, Sorbsan, Tegagel |
| What is the purpose of Foam dressings? | Highly absorbent, used in stage 2 and stage 3 pressure injuries. Ex. Flexan, Curafoam, Mepilex |
| What is the purpose Hydrocolloid dressings? | Minimal wound drainage, recommend for stage 2 pressure injuries, not recommended for infected wounds. Ex. CombiDERM, Comfeel, DuoDERM, Tegasorb |
| What are some main characteristics of veins? | Carry deoxygenated blood back to heart. Are thinner than arteries. Lower BP. They have valves, arteries do not. |
| What are Anastemoses? | Junctions where veins join other veins, or arteries join other arteries. |
| What are some Sites to Avoid during venipuncture? | 1. Other IV sites 2. Mastectomy on one side 3. arm with edema 4. Dialysis side |
| When is it best to use a needle and syringe method? | Smaller and more fragile veins of elderly and children. |
| What is Hemolysis? | The destruction of RBC's |
| When is it good to use a Butterfly? | For small or fragile veins, good for stbilization. |
| How often do you invert a phlebotomy tube after drawing for an anticoagulant? | 3-8 times gently |
| When should blood draw tubes be labeled? | After the specimen is drawn and attached before you leave the room. |
| How many times can you use the same touniquet? | once |
| Where do you place the tourniquet for a blood draw? | 3-4 inches above the site. |
| How long can a tourniquet be left in place? | No longer than 1 minute |
| What is the correct draw sequence and draw colors for blood samles? | 1st. Yellow or Blood Culture 2nd. Light blue 3rd. Red, Red and Gray, or Gold 4th. Green 5th. Lavender or Pink 6th. Gray 7th. Yellow |
| How many degrees should the needle be positioned and why? | 15-30 degrees. The larger the angle the deeper the vein, the more smaller the angle the more shallow the vein. |
| How should you move the needle once it has been inserted if it does not initially meet the vein? | Straight in or straight back, you can turn it slightly, but do not dig side to side. |
| What gets drawn first, anaerobic or aerobic blood culture? | Anaerobic (w/o O2) |
| When should bleeding always stop after a venipuncture? | Within 3-5 minutes. |
Created by:
merelisen3
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