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207 Cards in this Set

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How do you open the an inner package?
Grasp the center flaps and pull them open to the sides
What does an envelope-wrapped package allow?
The user to create a sterile field
What should you check for when using commercially packaged items? (5)
1. Tears
2. Holes
3. Worn areas
4. Water spot discoloration
5. Indication strips
How do you verify that gloves are sterile?
Look for the statement on the package
Sharps containers should be filled no more than...
2/3 full
What does the indicator strip on a sterile package suggest?
Evidence of sterilization
How are sterile supplies packaged by the manufacturer?
Wrapped in paper and then in plastic
What do you do with items that have been soaked in high-level disinfecting liquid?
Rinse thoroughly with sterile water before using
What do you do with an item before sterilizing or disinfecting?
Clean thoroughly to remove residue (blood and tissue)
Bacteria can surround themselves with a protective shell called...
An endospore
Small items are in these
Peel pouches
High level disinfection
Boiling for 10 to 20 minutes
If employee has latex allergy, who supplies latex-free gloves?
Employer
What is the most appropriate disinfectant agent used for contaminated surfaces?
10% bleach solution
When a contaminated spill occurs on campus, who is responsible for clean-up?
Instructor
What is work practice control?
Behaviors exhibited to promote safety
When should you create a sterile field?
As close to the procedure time as possible
"Skin to skin"
Slip two fingers of the ungloved hand under the cuff of the remaining glove
"Glove to glove"
Grasp the other glove with one hand to pull it off
How are packaged items sterilized?
Using ionizing radiation
Using very strong chemicals
High-level disinfection
If a health care worker refuses the HBV vaccine, what will happen?
May receive it at a later time and will be required to sign a refusal form
When a PCA gets a needle stick injury following a venipuncture, what could she do?
The source may be tested and the results revealed to the student
If a needle stick injury occurs, what steps should be taken? (3)
1. Purge the site until bleeding stops
2. Wash with soap and warm water
3. Disinfect with 10% bleach solution, if needed
What are some basic principles when using standard precautions?
Remove gloves before touching call light, side rails, or pen
What is included in Personal Protective Equipment? (3)
1. Gloves
2. Gown
3. Mask
What are subcuticular sutures? (3)
1. Placed underneath the dermis of the skin
2. Eventually absorbed by the tissue
3. Not seen on the outside of the skin
It prevents blood and other fluids from collecting in the wound
Drain
It maintains a moist environment and absorbs drainage
Dressing
These are less irritating to the skin than sutures, and cause less scarring
Staples
Adhesive strips that are placed across the top of an incision
Steri-Strips
Stitches; holds wound together
Sutures
Clear, watery wound drainage
Serous
Wound drainage that is mostly clear and watery, but tinged with blood
Serosanguineous
Wound drainage consisting of mostly blood
Sanguineous
A thick, yellowish fluid that is often the sign of infection
Pus
Pus-containing
Purulent
The fragile thin layer of new tissue and blood vessels that is formed during the proliferating phase of wound healing
Granulation Tissue
The removal of necrotic tissue
Debridement
Material used to hold a dressing in place
Bandage
A type of contamination that occurs when a sterile field contacts a wet surface
Strike-through contamination
This allows bacteria to stay alive but enter into a state of inactivity
Endospore
UAP
Unlicenced Assistive Personnel
Describes a procedure that involves inserting equipment into the patient's body or breaking the skin
Invasive
A health care facility that provides care for people who require a high level of care
Advanced (acute) care setting
To close a wound, the edges are said to be this
Well-approximated
These are used to reinforce a large incision
Retention Sutures
These are made of an absorbable material and placed right underneath the outer layer of the skin
Subcuticular Sutures
How can you prevent dehiscence in a patient?
Have the patient support incision site with a small pillow or folded towel while coughing or vomiting
What things should you observe on a wound? (3)
1. Excessive redness along the incision line
2. Increase in bloody drainage
3. Edges of wound are gaping
What are risk factors for dehiscence and evisceration? (3)
1. Obesity
2. Malnutrition
3. Infection at wound site
What are signs of a wound infection? (3)
1. Thick, yellowish fluid around the wound site
2. Excessive bleeding
3. Excessive redness along the incision line
An internal organ pokes through the wound
Evisceration
A sutured wound bursts along the suture line
Dehiscence
Sever, uncontrolled bleeding
Hemorrhage
Occurs if a pathogen gets into the wound
Infection
The wound is allowed to close on its own; there is increased risk of infection; often results in a large scar
Second-Intention Wound Healing
The wound is closed surgically at a later date after ensuring absence of infection
Third-Intention Wound Healing
The wound is closed surgically, as soon as possible
First-Intention Wound Healing
Why would a wound appear red and hot to the touch?
Because of increased blood flow to the area
What is the swelling and pain around the wound caused by?
Plasma leaking out of dilated capillaries into the surrounding tissue
Final stage of wound healing
Remodeling Phase
This page of wound healing begins 2 to 3 days after the injury and lasts up to 2 to 3 weeks in an uncomplicated wound
Proliferative Phase
This produces a thin layer of epithelial cells and promotes the growth of new blood vessels
Fibroblasts
The injury is red, hot, swollen and painful. What phase of wound healing is this?
Inflammatory Phase
What is the main cause of the development of arterial ulcers?
Inadequate blood flow to the tissues
This type of wound commonly occurs in people with decreased circulation
Chronic Wound
Related to exposure to high temperatures
Thermal
Tearing or cutting away of the skin with a dull instrument
Laceration
Slicing of the skin with a sharp instrument
Incision
Rupture of the blood vessels underneath the skin
Contusion
Rubbing or scraping away of the top layer of skin
Abrasion
A break in the skin that may involve the underlying tissues
Open Wound
Wounds that damage the tissues underneath the skin without breaking the skin
Closed Wound
Wound type that may never heal completely
Chronic
Health care associated infections (HAIs)
Nasocomial
These items only come in contact with intact skin
Noncritical Items
These are free of all microbes except for endospores and are processed using high-level disinfection
Sem-Citical Items
These items penetrate the skin or are placed into body cavities that are normally free of microbes
Critical Items
What do you do if you accidentally touch something that is not sterile?
Stop! Immediately back away from the sterile field and change your gloves
Why keep sterile items in the front center of the sterile field?
Prevents user from reaching across sterile field and contaminating
Why do we avoid reaching across a sterile field?
Small flakes of skin and hair can fall onto the field below and contaminate
Why do we have to keep sterile items above waist level or the work surface?
So you can keep it in your line of sight
Why do you have to clean and dry the work surface where a sterile field will be created?
Moisture could penetrate the sterile paper or cloth drape and contaminate it
What type of solution would e manufactured in a single-use bottle?
Normal Saline
To destroy most pathogens, except endospores
Disinfect
Absence of disease-causing microbes
Asepsis
Agent that slows the growth of microbes
Antiseptic
5 Rights of Delegation
1. The right task
2. " " circumstance
3. " " person
4. " " directions and communication
5. " " supervision
The UAP observes by (4)
1. Looking
2. Listening
3. Touching
4. Smelling
What should you never do as an UAP? (6)
1. Give medication
2. Insert or remove tubes or objects from the body
3. Take oral or telephone calls from doctors
4. Tell the patient or family diagnosis or medical or surgical plans
5. Diagnose or prescribe treatments
6. Supervise other personnel
What is the role of a UAP? (5)
1. Collect information
2. Determine the presence of a problem
3. Identify proper strategies with an RN
4. Perform delegated nursing care
5. Document nursing care provided
Isolation precautions (5)
1. Prevent drafts
2. Prevent contamination of equipment and supplies
3. Double bag items
4. Do not touch hair, nose, mouth, eyes
5. Use paper towels to turn faucets on and off
3 categories of Transmission-Based Precautions (isolation)
1. Contact Precautions
2. Droplet "
3. Airborne "
An infection or disease acquired in a hospital
Nosocomial Infection
8 signs and symptoms of wound infection
1. Redness and swelling
2. Drainage (color, odor)
3. Pain and/or tenderness
4. Fever
5. Fatigue
6. Increased pulse and respiration
7. Increased white blood count (WBC)
8. Elderly - confused, agitated, incontinence
5 main routes of transmission
1. Contact, direct and indirect
2. Droplet
3. Airborne (TB)
4. Common Vehicle (contaminated items)
5. Vector Borne (mosquitoes, flies, rats)
6 Chains of Infection
1. Infectious agent
2. Reservoir sight
3. Portal of exit
4. Mode of transmission
5. Portal of entry
6. Host
An acid fact bacillus that is spread through the air (coughing, speaking or singing)
Tuberculosis (TB)
Most common blood borne infection in US
Hepatitis C (HCV)
No vaccine for which hepatitis?
Hepatitis C
Inflammation of liver resulting from viral agents, bacterial agents or exposure to hepetotoxins or drugs such as tetrachloride or acetaminophen
Hepatitis
Procedures that help reduce risk of transmission of microorganisms
Standard Precautions
What is secreted during the remodeling phase of wound healing to strengthen the wound
Collagen
An injury that results in damage to the skin and underlying tissue
Wound
Indicators that a wound is infected (4)
1. Deep red color
2. More swollen than usual
3. Thick, greenish drainage
4. Foul odor
Indicators that a wound is healing (4)
1. Clean edges
2. Slight scab on the surface
3. Intact staples or sutures
4. Pink edges
Benefits of vacuum-assisted closure (VAC) therapy (3)
1. Removes wound drainage from the surface of the wound
2. Stimulates blood flow to the wound
3. Stimulates new tissue growth
Digestive enzymes of he body break down necrotic tissue
Autolytic Debridement
Gel or solution is applied to the wound
Enzymatic Debridement
Surgical instruments are used to remove necrotic tissue
Sharp Debridement
Maggots eat the necrotic tissue
Biological Debridement
Descriptions of open drain (2)
1. Fluid collects in the wound dressing
2. A sterile safety pin is used to prevent the drain from slipping back in the wound
Descriptions of closed drains (3)
1. Amount of drainage is measured and recorded
2. Suction is applied to actively draw drainage out
3. Consists of plastic tubing and collection device
How do decubitus ulcers form? (4)
1. Skin over a bony prominence is squeezed between hard surfaces
2. This prevents blood flow to skin and tissues
3. Oxygen and nutrients cannot get to cells
4. The skin and tissue die
What are the causes of decubitus ulcers? (4)
1. Pressure
2. Moisture
3. Friction
4. Shearing force
What do you observe when looking at a wound (documentation)? (6)
1. Location
2. Size LxWxD
3. Appearance - red, swollen, warm to touch, sutures, staples (intact or broken)
4. Drainage (COCA) - color, odor, consistency, amount
5. Drains
6. Pain level
Low or falling blood pressure, rapid weak pulse, rapid respirations, skin-cold, moist, and pale, restless, confusion, loss of consciousness
Shock
Things to do when measuring drains (4)
1. Note the number and size of dressings with drainage
2. Weigh dressings before and after removal
3. Measure amount of drainage in collection receptacle
4. Record on I&O form
What do you report to the nurse about a drain? (4)
1. Purulence
2. Foul odor
3. Redness around insertion site
4. Bleeding
When do collection reservoirs get emptied?
Every 8 hours and when 1/2 to 1/3 full
Closed drainage, sutured; drains by gravity
T-Tube
Closed suction drainage; sutured (2 words)
Jackson-Pratt
Closed suction drainage; sutured (1 word)
Hemovac
An open drain that drains exudate onto the dressing; no sutures; safety pin prevents slippage into the wound; drains by gravity
Penrose Drain
Thick green, yellow, or brown drainage
Purulent Drainage
Darker sanguineous drainage
Indicates older bleeding
Bright sanguineous drainage
Indicates fresh bleeding
Large amount of sanguineous drainage
Suspect hemorrhage
This is deposited in or on tissue surfaces during inflammatory and destructive phases of healing
Exudate
Signs and Symptoms of Infection (10)
1. Erythema and adema
2. Painful and tender
3. Drainage and odor (tan, cream, green, yellow)
4. Fever
5. Fatigue
6. Rash
7. Change in WBC
8. Loss of appetite
9. Mucous membrane sores
10. Elderly - confused, agitated, incontinence
Sometimes called delayed intention or closure; surgical wounds are left open 3 to 5 days and then stapled o sutured closed
Tertiary Intention
Open wound with tissue loss and jagged edges; there is a gap between the edges; granulation tissue gradually fills in the area of defect with scar tissue
Second Intention
Incision edges of a clean surgical incision remain closed; tissue loss is minimal and skin quickly regenerates
Primary Intention
Final stage of healing and may last for 1 year as the scar strengthens
Maturation Stage
Phase of Wound Healing
- Closure begins on day 3 and 4; continues for 2 to 3 weeks
- Fibroblasts with vitamin C & B for repair
- Collagen provides strength
- Epithelial cells duplicate damaged cells
Proliferative or Reconstruction Stage
Stage of Wound Healing
- Lasts 4 to 6 days
- Clots to scabs (homeostasis)
- Increased blood flow
- Redness and edema
- White blood cells clean cell's debris
- Epithelial cells move to the base of wound for 48 hours
Inflammatory or Defensive Stage
Why does skin age? (4)
1. Changes in elastic fibers in dermis
2. Increased fragility of blood vessels
3. Changes in membrane between the epidermis and dermis
4. Thickening of collagen
Open wound from a sharp object
Puncture Wound
Skin and underlying tissues are pierced
Penetrating Wound
Epidermis, dermis, subcutaneous tissue are involved and may involve muscle and bone (penetrating)
Full-Thickness Wound
Epidermis and dermis of the skin is broken (superficial)
Partial-Thickness Wound
A wound created for therapy
Intentional Wound
A wound resulting from trauma
Unintentional Wound
Skin or mucous membrane is broken
Open Wound
Functions of the skin (7)
1. Protection
2. Sensation
3. Movement without injury
4. Excretion
5. Vitamin D production
6. Immunity
7. Temperature regulation
Dead tissue, separating from viable tissue; moist, green (necrotic)
Slough
Thick, leathery black tissues (necrotic)
Eschar
Abnormal passage from an internal organ to the body surface or between two organs
Fistula
A pressure ulcer
Decubitus Ulcer
Wound with high risk of infection; usually unintentional
Contaminated Wound
A wound in which tissues are injured but the skin is not broken
Closed Wound
A wound that is not infected
Clean Wound
A wound that does not heal easily
Chronic Wound
How do you hold a bottle? (2)
1. Label in the palm of hand
2. 4 to 6 inches high
How long is sterile saline considered sterile after opening?
24 hours
The absence of all microorganisms on surface (keeping an area totally free of microorganisms)
Surgical Asepsis (Sterile Technique)
The absence of all pathogens; procedure used to prevent the spread of gems (hand washing)
Medical Asepsis (Clean Technique)
Killing of microorganisms, including spores
Sterilization
Hard-shelled cell produced by fungi or bacteria
Spores
Any microbe that causes a disease
Pathogens
Microbes that do not cause disease
Non-Pathogens
Agent that kills germs
Germicide
How are instruments and equipment sterilized?
By using heat (steam under pressure)
Wound Observations (9)
1. Size
2. Location
3. Wound edges
4. Underlying tissues
5. Color, odor, consistency, amount (COCA)
6. Closures
7. Drainage and drains
8. Tenderness and swelling
9. Pain
Catheters inserted into the cephalic and basilic veins by physician or RN
Peripherally inserted central catheters (PICC)
Inserted by a physician into a large vein (subclavian, internal jugular)
CVC
What do you teach patients regarding calling for help about IVs?
Call for help if pain, swelling, leakage or alarms go off
How do you monitor IVs?
Check hourly...
Site, drip, tubing
IV - Clot, kinking of tubing, arm position
Decreased Flow
IV - Leaking of fluid into tissues, needle dislodged; pallor, swelling, coolness, pain
Infiltration
Inflammation of vein due to mechanical trauma and/or chemical irritation; redness, warmth, pain and swelling
Phlebitis
Has the appearance of a "T" and is used to secure rectal or perineal dressings
T-Binder
*Double T-Binder for Males
Applied over or around dressings; can provide extra protection and therapeutic benefits
Binders
Used for large dressings and when frequent dressing changes are needed
Montgomery Ties
Tape that allows for movement of the body part
Elastic Tape
Non-allergenic Tape
Paper or plastic tape
Sticks well to the skin, difficult to remove, film left on skin, can irritate skin
Adhesive
Chloroprep
Chlorahexidine
.9% Sodium Chloride
Normal Saline
Antimicrobial, germicidal, topical anti-infective
Povidone Iodine
1/4 vinegar, bladder irrigation, antimicrobial for treatment of superficial infection
Acetic Acid
H2 O2
Hydrogen Peroxide
Sodium-Hydrochlorite; very weak bleach solution; kills bacteria (antiseptic)
Dakins
A clear, adherent, non-absorptive dressing that s permeable to oxygen and water vapor but not to water
Film Dressing
A gauze dressing saturated with solution applied or packed into the wound; the solution softens dead tissue
Wet to dry dressing
A gauze dressing placed over the wound; drainage is absorbed by the dressing and removed with the dressing (may stick to wound)
Dry Sterile Dressing
Prevents fluid and bacteria from entering the wound but allows air into the wound; drainage not absorbed; allows for wound observation
Transparent Adhesive Film
A gauze dressing with a non-stick back (i.e. Telfa)
Non-Adherent Gauze
Packaged in squares, rectangles, pads, rolls and fluffs; absorbs moisture
Gauze
Bed cradle, heel elevators, floatation pads, air mattress
Protective Devices
Foam dressing connected to a canister
Vacuum Assisted Closure Therapy
Applied over wounds treated with enzymes, irrigation, wet to dry dressings, etc.
Gauze Dressing
Used to secure non-adherent dressings; prevents skin irritation and tearing
Hypoallergenic Tape
Protective and will prevent wound dehydration; also absorbent
Foam
Highly absorbent of wound exudate
Exudate Absorbers
Dressing that facilitates wound healing, very soothing
Hydrogels (dressings)
This dressing maintains moist environment for wound to heal and keeps skin dry; can protect skin from shearing and friction
Hydro-coiled Dressing
Dressing applied over superficial ulcers and skin subjected to shear
Transparent Dressing
What do RNs use as an assessment tool for patients at risk for skin breakdown?
Braden Scale
Pressure Ulcer Stage: Muscle and bone exposed, muscle and bone damaged, drainage likely, infection, surgical repair to heal
Stage IV
Pressure Ulcer Stage: Dermis and epidermis gone, underlying tissue exposed, drainage, infection
Stage III
Pressure Ulcer Stage: Skin breaks, drainage, some necrosis, infection develops, shallow crater
Stage II
Pressure Ulcer Stage: Reddened area, does not blanch, elevated skin temperature, tissue edema, discomfort
Stage I
Documentation of Wound (10)
1. Procedure performed
2. Type of dressing and solutions
3. Observations
4. Signs of Infection
5. Drainage
6. Patient teaching
7. Patient tolerance
8. Side rail status, call light, bed position
9. Notification to RN, if applicable, and why
Rules for Documenting (7)
1. Date and time (military)
2. Sign all entries with name and title
3. Record only what you observed and did
4. Record in logical and sequential manner
5. Use client's exact words
6. Record safety measures (call lights, side rails, bed position)
7. What you observed, did and client's responsible
Example of Documentation...
12/03/13 1300. Rt. hip dsg changed. Old dressing with scant amount of serosanguineous drainage without odor. Well-appoximated suture line with five stitches intact, without redness or edema. Incision line cleansed per policy. New gauze pad placed and secured with tape. Pt. rates pain 2/10 during procedure. Side rails up, call light within reach. Bed in low position. RN notified............R. Leffingwell, PCA.