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