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Nursing
Sterile Technique
| Question | Answer |
|---|---|
| Medical Asepsis | Clean technique: reduce or prevent the spread of microorganisms |
| Surgical Asepsis | Sterile Technique: eliminate all microorganisms |
| Cleaning | Removal of all soil from an object or surface |
| Disinfection | Elimination of many germs from inanimate objects |
| Sterilization | Elimination of germs from inanimate object |
| WBC | 5,000-10,000 normal range |
| Principles of Surgical Asepsis | Moisture may cause contamination. Always assume that an object is unsterile (check integrity of packaging. check label for expiration date). Always face sterile field. Only sterile to sterile; unsterile to unsterile. Keep sterile equipment above waist. |
| Sterile solution bottles must be marked with: | Date, time opened, nurse's initials. Discard sterile solutions 24-48 hrs after opening. |
| Applying Sterile Gloves | Place first sterile glove on dominant hand by grabbing turned down part of the cuff. Touch only the inside of glove with unsterile hand. Slip sterile gloved hand underneath second cuff. Adjust fit after both are on. Maintain gloved hands above waist. |
| Removing Sterile gloves | Grasp outer surface with gloved hand. Roll off first glove- placing it in palm of your other gloved hand. Place ungloved hand under remaining glove on thumb side. Slide off remaining glove. Discard both in balled condition. |
| Dressing Change Procedure | Check order, medicate & position PRN, gather supplies, cut tape, wash hands, move garbage can close to bed, apply clean gloves, remove old dressing, assess wound, remove dirty gloves, wash hands, open all bottles & packages, date, time, initial, don glove |
| Dressing Change Procedure cont | Cleanse wound, dry surrounding skin, dress wound, remove dirty gloves, wash hands, document |
| Gauze Pads | 2x2s, 3x3s, 4x4s folded gauze. Can be used sterile or clean. Used as a primary dressing: next to wound. Special types: lodoform, Vaseline, xeroform |
| Fluffed and rolled Gauze | Large pieces of layered gauze. Loosely folded to absorb drainage, used for packing or wrapping wounds, used to secure dressings on extremities and head |
| ABD Pads | Combine, combination pads. Large absorbent pads. Used as a secondary dressing- over a primary dressing, not against skin. Used with high absorbency is needed. |
| Hydrocolloid dressings | Duoderm, Soft wafer that can be cut to desired shape & size. Absorbs small amounts of drainage. Autolytic debriding of necrotic wounds. Used on stage 1 & II pressure sores. Protects from high friction areas. Can remain in place up to one week |
| Non-Stick dressings | Telfa. Non-adherent. Used directly on wound or incision to prevent injury to tissue when the dressing is removed: band-aide. Can be impregnated with petroleum or antimicrobials. |
| Transparent dressing | Manage superficial wounds. Provide skin protection. Allows visualization of site: IVs. Allows autolytic debridement of small wound when removed. Moisture/vapor permeable-allows gas to pass thru. Used over black eschar |
| Skin barriers | Used to protect skin from stool, urine, and drainage. Comes in wafer, paste, or powder. Can be used as an anchor for tape to prevent skin irritation |
| Montgomery Straps | Anchoring pieces applied to intact skin adjacent to wound. Laces crisscross over wound to secure large or bulky dressing that need changed frequently. Helps to avoid skin irritation caused by frequent tape removal |
| Tape | Various widths. Variety of materials: paper, silk, plastic, adhesive. Steri-strips: used to approximate incisions of lacerations not requiring stiches. |
| Isotonic Solutions | No antibacterial action. Removes exudates. Moisturizes wound surfaces. Commonly used to cleanse wounds. Sterile Normal saline. Lactated Ringer's. |
| Sterile Hydrogen Peroxide | Used for mechanical debridement of open wounds. Causes too much trauma with effervescent action for deep tunneling wounds. Removes blood clots-not used for fresh bleeding wounds. No sustained antiseptic action. Not used in full strength. |
| 2% Chlorhexidine Gluconate | Kills: bacteria, spores, viruses, fungi. Affective pre-op skin antiseptic and surgical scrub. Toxic to granulation tissue. When using on infected wound use at <1% strength |
| Drains | Enhances flow of drainage from wound. Prevents accumulation of drainage. Promotes wound healing. |
| Drainage | Serous: serum from body, pale yellow, watery, fluid blister-like. Sanguinous: bloody. Serosanginous: Blood and serum, red-pink. Purulent: pus, pale yellow to green, WBCs, infection. |
| 1st degree Burns | Least severe. Reddened area: sunburn. |
| 2nd degree burns | Blisters form |
| 3rd degree burns | Skin is charred or nonexistent. Severe fluid loss, nerve destruction. Requires debridement and grafting. |
| Dry Sterile Dressing | Wound with little to no drainage. Protects wound from injury. Prevents introduction of bacteria. Reduces discomfort. Speeds healing. Used on abrasion, non-draining postop incisions. Moisten with SNS to reduce trauma when removing dressing. |
| Wet to dry/Damp to dry Dressing | Mechanical debridement with removal of dressing. Common in deep wounds requiring packaging-eliminate dead space. Moisten gauze/rolled-open and fluff. Cover with DSD. |
| Pressure Dressing | Used for temporary control of excessive bleeding following: trauma, surgery, puncture. May stop bleeding. May be combined with sandbag use. |
| Absorption Dressing | For wounds with moderate to large amounts of drainage. Wicks drainage from wound. Comes in paste, granules, sheeting, or rope forms. |
| Wound Vacuum Assisted Closure (VAC) | Assists in wound closure by applying negative pressure to draw the edge of wound together. Accelerates healing. Reduces edema. Improves circulation. Reduces bacterial counts in wound. |
| Nursing Diagnoses | Risk for infection. Impaired Skin integrity. Pain. Impaired Tissue Integrity. Body image disturbance. Imbalanced nutrition. |
| Chain of infection | Infectious agent (bacteria, fungi, virus) -> source (human, animal, inanimate object) -> portal of exit (sputum, stool, blood) -> mode of transmission (contact, vehicle, airborne) -> portal of entry (mucous membrane, nonintact skin, GI/GU tract) |
Created by:
senmark
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