Skills

Front 1

Difference between Medical & Surgical Asepsis

Back 1

Medical = "clean technique" (a decrease in microorganisms)

Surgical = "sterile technique (no microorganisms)

Front 2

What should you do with your gloves and alcohol wipes if the pt is under isolation precautions?

Back 2

Take them out of your pocket if they are there and put them on bedside table.

Front 3

Equipment - Sterile Wound Dressing Change

Back 3

* Kit w/ 1 pr gloves, 4x4 gauze (1 2-pk), Q-tips, Tape (paper), Saline, 2 pr gloves, measuring device
- from kit, throw out: drape, curlix, gauze
* Packing:
- Kit - nacho plate, 4x4s, tapes, 1 pk Q-tips, ABD, 1 pk gloves
- outside kit - 1st set gloves, measuring device, tape, 1 pk Q-tips, saline

Front 4

Maceration (w/ regard to condition of surrounding tissue)?

Back 4

moisture (like prune fingers after a bath)

Front 5

Excoriation (w/ regard to condition of surrounding tissue)?

Back 5

scratches of the epidermis

Front 6

Erythematous (w/ regard to condition of surrounding tissue)?

Back 6

redness

Front 7

3 ways to classify wounds?

Back 7

1) intentional or unintentional

2) Open or Closed

3) Acute or Chronic

Front 8

Most common Chronic wound?

Back 8

Pressure Ulcer

Front 9

What's the defining characteristic of "un-approximated" wounds?

Back 9

jagged edges

Front 10

What to assess on a wound?

Back 10

- approximation of edges
- integrity of sutures/staples
- redness (erythema)
- discoloration
- warmth
- swelling (edema)
- unusual tenderness
- drainage
- surrounding tissues
- maceration, excoriation, erythematous

Front 11

Primary Intention (in relation to wound healing)

Back 11

Intentional closed wound (closed incision lines)
Intact incision line
Dry, sterile dressing

Front 12

Secondary Intention (in wound healing)

Back 12

Intentional or unintentional open wound
- Incision line re-opens
- Inf. surgical wound/contaminated traumatic wound
Sterile dressing change

Front 13

Tertiary Intention

Back 13

Intentional or unintentional open wound (left open from the beginning - can see wound bed)
- Large surgical defect
- Major trauma or burns
- Sterile saline dressings
- Possible skin grafting

Front 14

When & why would you leave a wound open?

Back 14

In a secondary or tertiary intention.
Because it needs to heal from the inside out or it can increase r/o repeat infection.
& prevents abscess.

Front 15

STERILE WOUND MANAGEMENT – NOTES/ POSSIBLE TQ

Back 15

X

Front 16

Difference between medical & surgical asepsis?

Back 16

-Medical asepsis = clean technique (decreases micorganisms)
-surgical asepsis = sterile technique (NO microorganisms)

Front 17

Most solutions are considered sterile ______ hrs. after they are opened? (if closed for further use)

Back 17

24 hrs

Front 18

What are typical ways to classified wounds?

Back 18

-intentional or unintentional
-open or closed
-acute or chronic

Front 19

Most common wound?

Back 19

pressure ulcer

Front 20

What kind of wound is one with jagged edges? Example?

Back 20

unapproximated (pressure wound)

Front 21

Describe a “primary intention” wound.

Back 21

-closed, incision lines intact
-dry, sterile dressing

Front 22

Describe a secondary intention wound.

Back 22

-infected, incision reopens, etc (needs intervention)
-requires a sterile dressing change
- usually moist→dry & leave it open

Front 23

Why would you leave the Secondary intention wound open after re-dressing?

Back 23

needs to heal inside→out or can ↑ r/o infection

Front 24

Describe a tertiary intention wound. Why would it be used?

Back 24

-left open from the beginning (can see wound bed)
-Used for large surgical defect
-major trauma or burns
- sterile saline dressings
- possible skin grafting
- used to prevent an abscess

Front 25

Factors affecting wound healing?

Back 25

-Age
-circulation & oxygenation
-nutrition & hydration
-health status

Front 26

Things used to drain a wound? Describe them.

Back 26

-Open drain
- Penrose drain – acts as a sinus/pathway
-Closed drain
- Jackson-Pratt (JP) – pulls out drainage w/ negative pressure
- Hemovac – Accordian style

Front 27

Why can let a Jackson-Pratt drain fill completely?

Back 27

negative pressure will be gone

Front 28

When would a Hemovac be used?

Back 28

hip or mastectomy

Front 29

What care should be taken when draining a ventricle, CSF, etc?

Back 29

drain slowly

Front 30

How are wounds describe by color?

Back 30

- red: healing = protect
- yellow: infected or draining = cleanse
- black: necrotic (aka. eschar) = debride
- also “sloughing” wound = dying tissue falling off

Front 31

Examples of “mechanical” wound treatment?

Back 31

-moist to dry dressings
-irrigation by whirlpool or syringe

Front 32

Example of “chemical” wound treatment?

Back 32

Proteolytic enzymes – eat dead tissues

Front 33

Pressure ulcer stages:

Back 33

1) Red, non-blanching, skin in tact
2) Open blister – no epidermis, see dermis
3) Adipose tissue visible
4) underlying structures visible (muscle, bone, etc.)
5)unstageable – eschgar on wound

Front 34

What is granulation tissue & what is the best environment for it?

Back 34

healthy tissue, moist environment

Front 35

4 words for describing wound drainage?

Back 35

1) Serous = clear, watery
2) Purulent (infected) = thick, yellow, green, tan (cloudy)
3) Serosanguineous = pale, red, and watery
4) Sanguineous (fresh) = bright red, active bleeding

Front 36

Why is a purulent drainage cloudy?

Back 36

due to the presence of white blood cells/
What does “Dehiscence” refer to in wound complications?
*opening of wound layers (muscle intact)

Front 37

What does “Evisceration” refer to in wound complications?

Back 37

protrusion of internal organs (muscle separated)

Front 38

What is a “Fistual formation”?

Back 38

abnormal opening from organ→organ or organ→skin

Front 39

What could cause a Fistula?

Back 39

chemo Tx

Front 40

What is the first nursing action with an Evisceration?

Back 40

-Do NOT leave the pt., keep moist but don’t be concerned with sterile at that moment (organ already outside of body)
-position in low fowler’s
-cover wound with sterile towels moistened w/ 0.9% NaCl solution

Front 41

Basic principals of Surgical Asepsis?

Back 41

-open package away from you
-do NOT pour liquid onto cloth or paper field (unless plastic backed)
-Keep sterile objects in sight & above waist & below shoulders
-avoid creating air currents (stirs up fomites)
- close door or curtains
- limit talking, do not cough or sneeze

Front 42

What should be monitored?

Back 42

- excessive drainage that may overwhelm dressing
- change soiled or loose dressing

Front 43

What considerations can be taken for older adults with ↓ skin elasticity & ↑ sensitivity?

Back 43

-paper tape
-roller gauze on extremity dressings
- skin protectant (hydrocolloid dressing) under tape
-montgomery straps – for excessively changing dressings (heavily draining)

Front 44

What if the dressing is dry upon removal?

Back 44

reduce the time between changes to prevent drying of the materials (may disrupt healing tissue)

Front 45

When removing a pt’s dressing, the assessment reveals eschar in the wound?

Back 45

notify PCP or specialist to consult about different Tx or possible debridement.