Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
STERILE TECH
STERILE TECHNIQUE-WOUND CARE CH 12,13,18
| Question | Answer |
|---|---|
| INFECTION CONTROL | Pt teaching of infection process & signs and symptoms, explanation of clean vs. contaminated items, Aseptic technique to prevent infection, teach apps of aseptic principlesto self-care |
| HEALTH PROMOTION considerations for Infection Control | Importance of adequate exercise,well-balanced diet and Immunizations.Safe methods of food storage. Good methods of Hygiene. Be aware of susceptible family members. Prepare enough formula -8hrs & 4 hrs the home made type.Clean linen separately |
| NOSOCOMIAL INFECTION | Can result from improper hand hygiene & contaminated equipment. |
| CDC Hand Hygiene Guidelines-Care of all Pts | Use alchol-based hand rub if nurse comes n contact with the pt, pt's secretions, medical equip nearby pt, after removing gloves. Before eating & after using bathroom. Use hand lotions t prevent irritant contact dermititis.No fake nails. |
| SURGICAL HAND ANTISEPSIS | CDC Recommends 2-6 mins Association of Operative RN recommends 5-10 min Using knee or foot controls for water cLEAN NAILS with NAIL PICK-Scrub w/ 15 strokes 10 strokes-hands,fingers.. Elevate hands after rinsing Dry in rotating motion |
| MASK/PROTECTIVE EYEWEAR | Change it 20-30 mins afterwards or when it becomes moisten. In order to prevent pathogens |
| DOUBLE BAGGING | Infection control practice that involves placing a bag of contaminated items into another, clean bad that is held outside an isolation room by other personnel. Color coded & labeled |
| ISOLATION- Negative-pressure TB | Negative pressure airflow to prevent infectious particulates from flowing out of the room |
| ISOLATION- Positive-pressure Transplant pts | Airflow used for highly susceptible pts such as transplants recipients. No organisms are able to enter the room |
| PRECAUTIONS | AIRBORNE= Airborne droplet nuclei-Measles,TB,Varicella DROPLET= Serious illness transmitted by lg particle droplets- Meningitis,pneumonia,Influenza TB ISOLATION- Known or suspected TB. Single-pt room & negative air flow |
| WOUND CULTURE | Swab center of wound site.Insert swab without touching outside of tube |
| BLOOD CULTURE | 10mL per culture bottle. Perform venipuncture @ 2 different sites to decrease chances of contamination by skin flora |
| STOOL CULTURE | Take sample with glove, tongue blade to get small amt then placing it into the cup.Collect it from bedpan |
| URINE CULTURE | Use alcohol swab pad, syringe, and needle to collect it if there is a Foley Cath.Obtain clean-voided specimen 1-5 mL amt needed |
| Isolation technique | Determen cause. Equipment for VS should stay in the room. Nurse's watch should be on a clean paper towl or plastic bag placed on bedside. Pt should be taught the rationale of isolation, they need extra time (psych. affects) |
| AIRBORNE PRECAUTIONS | Pts transmitting AIRBORNE DROPLET NUCLEI- MEASLES,VARICELLA,TUBERCULOSIS. |
| DROPLET PRECAUTIONS | Serious illnesses with LARGE PARTICLE DROPLETS: INFLUENZA,-Meningitis, pneumonia,epiglottis & sepsis-, PERTUSSIS,PNEUMONIC PLAGUE,PHARYNGITIS/SCARLET FEVER,ADENOVIRUS,MUMPS,RUBELLA... Work 3 ft of Pt |
| TB ISOLATION- Negative Pressure room/AFB treatment rooms | Suspected TB: rESPIRATORY symptoms lasting > than 3 weeks. Symptoms: Fatigue,weight loss, dyspnea,fever,night sweats & cough (also w/ blood. Wear N-95 or HEPA respirator. |
| CONTACT PRECAUTIONS | Disease transmitted by direct pt contact: GI,RESPIRATORY,SKIN-(Herpes,cellulitis,decubiti,Pediculosis,Scabies)- OR WOUND infection Enteric Infections: E. COLI,SHIGELLA,HEP A, ROTAVIRUS Wear gown if pt: INCONTINENT, Diarrhea,Ileostomy,Colostomy or Wound |
| IMMUNOCOMPROMISED PTS | Susceptibility to Nosocomial infections from exogenous & endogenous sources. LEUKOPENIC pts require addt'l protective measures |
| SURGICAL ASEPSIS | Absence of all microorganisms, including pathogens and spores. |
| Sterile Techniques | Changing Dressings: Handwashing & sterile gloves 1-Assemble equip 2-Surgical hand scrub-remove debris-2-3 min 3- surgical attire 4- Sterile pack.-"event-related" contaminated-UNSTERILE |
| STERILE Principles | Sterile touching Sterile = STERILE Sterile objects on sterile surface Objects above Waist No talk, laugh or sneeze Open it as close as possible to sterile field Any wet surfaces= CONTAMINATED (no MOIST) |
| STERILE field | 1 inch of border can be touched when opening packages, Place them in the center of surface Open outer flap away from body Do not allow flaps to springback over sterile contents |
| POURING STERILE SOLUTIONS | Cap is placed up, to protect sterile side Bottle should be held w/ label in the palm of the hand "Lipping" 1-2 mL-discarded to clean lip Bottle should be held outside edge of sterile field |
| Open Gloving vs Closed Gloving | OPEN: dressing changes or Urinary cathereter insertions CLOSED: When sterile gowns are used (Operating rooms & special treatment areas)-Glove dominant first |
| BACTERIOSTATIC SOLUTIONS | Antiseptics- inhibit the growth of microorganisms but DO NOT kill them. May be used on human tissue- surgery, wounds,mouth care & handwashing |
| STERILIZATION- PHYSICAL METHOD | Heat / radiation - Steam under pressure or moist heat for destruction of microorganisms. -Boiling water is the best method for home use (will not destroy spores & viruses) -Radiation sterilizes pharmaceutical goods,foods & heat sensitive -Dry heat- |
| STERILIZATION- CHEMICAL METHOD Iodine,Alcohol & chlorine bleach | Gas- (Ethylene Oxide)- Destroys spores Chemical Solutions- effective in destroying microorganisms SURGICAL- All organisms be destroyed MEDICAL Asepsis- Only removal of pathogens |
| Older Adult Infection Control | Promote Oral Hygiene-Mucosa integrity DECREASE Digestive Acid- Wash hands,careful w/ food SKIN- thinner, elasticity decreased Urethral stricture,neurogenic bladder & prostatic enlargement Decrease in rib cage during inspiration-encourage to cough & br |
| • GRANULATION | soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen |
| • COLLAGEN | Occurs during reconstruction, Fibroblasts make collagen, which is a gluelike protein substance that adss tensile strength to the wound and tissue |
| • SINUS | sac or cavity in any organ or tissue |
| • CELLULITIS | Infection of the skin characterized by heat, pain, erythema and edema |
| • KELOID | Overgrowth of collagenous scar tissue |
| • ADHESIONS | Band of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in the abdomen |
| • PHAGACYTOSIS | Process by which certain cells engulf and dispose of microorganisms and cell debris; occurs when exudate from the injured cell is surrounded |
| • SLOUGHING | tissue coming off |
| • SEROUS | Thin and watery, composed of the serum portion of blood (Clear, watery plasma) |
| • SEROSANGUINEOUS | Thin and red, composed of the serum and blood (Pale,red,watery; mixture of serous & snaguineous) |
| • SANGUINEOUS | Pertaining to blood (bright red; indicates active bleeding) |
| • PURULENT | Producing Pus- (Thick yellow, green, tan or brown) |
| • ECCHYMOSIS | subcutaneous hematoma larger than 1 centimeter, commonly called a bruise. It can be located both in the skin as well as in a mucous membrane. |
| • INFECTION | the invasion and multiplication of microorganism in body tissue which causes cellular injury |
| • FISTULA | abnormal passageway or tract between an internal organ and the skin or between 2 internal organs. May be congenital or caused by an infection. Example rectovaginal fistula, biliary fistula, AV fisula for dialysis patients |
| • HEMATOMA | localized collection of blood underneath tissue |
| • ABRASION | wound consisting of superficial damage to the skin |
| • DEHISCENCE | Separation of a surgical incision or rupture of a wound closure |
| • EVISCERATION- | Protrusion of an internal organ thorugh a wound or surgical incision |
| • UNDERMINING | going under the skin flap of the wound |
| • TUNNELING | going downwards into the wound.Use the face of a clock to indicate where the undermining/tunneling is |
| • DEBRIDEMENT | process of removing de-vitalized, or dead tissue from a wound bed. Devitalized tissue can appear yellow, tan, or black in color, and can be dry or wet. Devitalized tissue can impede the healing process autolytic, mechanical, enzymatic, and surgical. |
| • INFLAMMATION | Cells migrate divide, and form new cells. Blood clots dissolve and wound fills, usualy meets 24-48 hrs |
| • ERYTHEMA | redness |
| • INDURATION | dermal thickening causing the cutaneous surface to feel thicker and firmer. |
| • AUTOLYTIC | known as self digestion refers to the destruction of a cell through the action of its own enzymes. debridement is the process the body undertakes to |
| • ASEPSIS | Absence of germs |
| • PRIMARY INTENTION | Primary union:when wounds that are made surgically and that have little tissue loss heal, skin edges are together and this begins in the inflammatory phase of healing |
| • Evisceration | intestines coming through |
| 1. *1.Clean Wound | Uninfected surgical wound |
| 2. *2.Dirty wound | 27% chance of causing a wound infection (gangrene) |
| 3. *3.Contaminated wound | (Clean contaminated wound)-Results form the presence of GI products- (Ex: feces, with Escherichia coli in the colon)- from an acute, nonpurulent inflammation (infection-10% to 17%) |
| Necrotic wounds | consider Dakin’s |
| Inflammatory Phase | Caused by the Increase in blood elements- antibodies,electrolytes, plas, and protein- Cells migrate divide, and form new cells. Blood clots dissolve and wound fills, usually meets 24-48 hrs. |
| Cardinal Signs | Erythema,Edema, heat, pain, loss of function |
| 2. Reconstruction/proliferation Phase | wound's appearance changes to irregular, raised,purplish, immature scar- Collage / Granulation- |
| • -Granulation tissue | soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen |
| • -Collagen | Occurs during reconstruction, Fibroblasts make collagen, which is a gluelike protein substance that adss tensile strength to the wound and tissue |
| Remodeling/Maturation Phase | final result, reorganization of the collagen formed scar tissue. May take up to two years or longer to heal depending on the type of wound and the pt’s history. Internally scar tissue can create problems (adhesions |
| -Keloid | may form at the site of wound (overgrowth of collage nous scar tissue) |
| Primary Intentions | Tissue edges are approximated with use of sutures or staples .Minimal tissue loss and scar formation .Ex. Surgical incisions cutting yourself with a knife |
| .Secondary Intentions GRANULATION | Extensive damage to tissue that the edges cannot be approximated or when pus has formed • -Usually left open and allowed to heal from the inside out Decubiti, burns and severe lacerations |
| Tertiary Intention | delayed or secondary closure • -Wound is left open for a period of time • -After it has healed without infection, then two layers of granulation tissue are sutured closed and wound is allowed to continue the healing process |
| Fistula = | abnormal passageway or tract between an internal organ or skin; or between two internal organs. May be congenital or caused by an infection *Rectal vaginal fistula is common during post surgery* |
| • -Petechiae = | Look really small; broken blood vessels (little dots) |
| • -Ecchymosis = | are bigger than petechiae |
| • -Sloughing = | tissue comes off on dressing |
| • -Undermining = | use q-tip you go underneath the surface |
| • -Tunneling (sinus tract)= | use q-tip going downward in the decubits (measure it using face of a clock) |
Created by:
510756990
Popular Nursing sets