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271 Cards in this Set
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Asepsis ***
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absence of microorganisms that produce disease (pathogens); the prevention of infection by maintaining a sterile condition
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Contamination ***
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when something is rendered unclean or unsterile; an item, surface, or field is considered to be contaminated whenever it has come into contact with anything that is not sterile
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Decontamination ***
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use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens (to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal)
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Disinfection ***
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the destruction or removal of pathogenic organisms, but not necessarily their spores
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Hepatitis ***
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inflammation of the liver
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Infection ***
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the production of a disease or harmful condition by the entrance of disease-producing germs into an organism
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Isolation ***
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separation from others
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Medical asepsis ***
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practices that help to reduce the number and spread of microorganisms. (Our goal)
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Microorganism ***
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a tiny living animal or plant that can cause disease
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Nosocomial ***
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- pertaining to or originating in a hospital
- nosocomial infection may be referred to as a healthcare-associated infection (HAI) |
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Pathogen ***
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microorganism that produces disease
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Sepsis ***
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presence of pathogenic microorganisms or their toxins in the blood or tissues
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Spore ***
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a hard, thick-walled capsule formed by some bacteria that contains only the essential parts of the protoplasm of the bacterial cell
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Sterile ***
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containing no microorganisms; free from germs
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Sterilization ***
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process by which all microorganisms, including spores, are destroyed
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Surgical asepsis ****
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practices that render and keep objects and areas free of all microorganisms
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How can one enhance his/her protection from a pathogen or microorganism?
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by interrupting the cycle of infection
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When the cycle of infection is interrupted the microorganisms cannot...
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grow, spread, or cause disease
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The place where microorganisms can grow and reproduce
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host or reservoir
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List the steps in the cycle of cross-contamination and infection ***
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1) reservoir for organism and host (e.g., person with MRSA infection)
2) method of exit for the organism (e.g., draining wound) 3) method of transmission of the organism (e.g., soiled dressings, exudate from the wound, soiled linen) 4) method of entry of the organism into a new host (e.g., cut, abrasion, cuticle tear, or any break in the skin) 5) susceptible host (e.g., person with low or limited systemic resistance to the organism) 6) infection develops in new host |
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What are some barriers that can be used to interrupt the cycle of cross-contamination and infection?
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- proper disposal of dressings and linen
- use of Standard Precautions - use of protective clothing - proper hand hygiene |
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By what means can microorganisms leave the host?
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- nose
- mouth - throat - ear - eye - intestinal tract - urinary tract - multiple body fluids (especially blood) - wounds |
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List the five primary cross-contamination transmission routes. ***
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- contact
- droplet - airborne - common vehicle - vector-borne |
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What is the contact route of cross-contamination? ***
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direct contact with the host or indirect contact with the host's linen, equipment, instruments, eating utensils, body fluids, etc.
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What is the droplet route of cross-contamination? ***
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sneeze, cough, talking, etc.
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What is the airborne route of cross-contamination? ***
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evaporated droplets, dust particles, etc.
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What is the common vehicle route of cross-contamination? ***
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food, water, medications, etc.
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What is the vector-borne route of cross-contamination? ***
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mosquitoes, flies, rats, etc.
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In what type of environment do microorganisms proliferate best?
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dark, warm, moist
thus, expose them to light, cool (or extremely hot), and dry environments |
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What are some spore-producing diseases?
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- anthrax
- botulism - histoplasmosis |
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What is the difficulty in dealing with spores?
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they have thick, hard, protective walls and are very difficult to destroy, especially when they are located deep in a wound
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What are the three most common means of transmission?
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- contact
- droplet - airborne |
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What diseases might require a patient to be kept in isolation (or with a cohort)?
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- TB
- hepatitis - staphylococcal or streptococcal infection |
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What is a "clean approach"?
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the use of extreme care when removing protective clothing after treating a patient who is in isolation to reduce cross-contamination
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What bodily fluids are capable of transmitting pathogens?
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- tears
- perspiration - mucus - vomitus - blood - semen/vaginal secretions - urine - feces (um, saliva?) |
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What is the primary barrier to pathogens?
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intact skin
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What should be the assumption for each and every patient with which you come into contact?
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assume they have a transmissible or infectious disease and treat them as such
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What is the CDC's two-tiered approach to infection and isolation precautions?
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- Standard Precautions (more important)
- Transmission-based Precautions |
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When are Standard Precautions used? ***
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all healthcare workers should use Standard Precautions at all times
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What are Standard Precautions designed to do? ***
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- designed to protect health care workers and patients in a hospital regardless of their diagnosis or infection status
- considered to be the best means to control nosocomial infections (a.k.a. healthcare-associated infection) |
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To what do Standard Precautions apply? ***
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apply to blood, all body fluids, secretions, and excretions EXCEPT SWEAT, regardless whether they contain visible blood; nonintact skin; and mucous membranes.
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Under Standard Precautions, what should be assumed about the bodily fluids of patients? ***
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- assume that every direct contact with a patient’s body fluids is potentially infectious
- this protects against the transmission of undiagnosed and diagnosed infections |
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What are Transmission-based Precautions designed to do?
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protect the caregiver from specialized patients with highly transmissible pathogens who are known or suspected to be infected by epidemiologically important pathogens that can be spread by
- direct contact with dry skin or contaminated surfaces, - droplets of moisture, or - airborne particles |
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When a person is in isolation, specific actions designed to interrupt the route of transmission of pathogens from the patient must be followed by:
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any person who enters the patient's environment
the specific barriers used to interrupt the route of transmission will depend on the type of disease or infection, and, most importantly, the mode of transmission of the pathogens |
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What are the three designations of Transmission-based Isolation precautions? ***
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- Contact Precautions
- Droplet Precautions - Airborne Precautions |
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Transmission-based Isolation precautions are used in addition to...
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Standard Precautions
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Standard Precautions represent: ***
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a system of infection control in which it is assumed that every direct contact with a patient's bodily fluids is potentially dangerous
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Items to consider under standard precautions ***
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- barriers
- hand care - sharps |
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Barriers under Standard Precautions ***
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- protective clothing
- mask - eye protection/face shield - gloves - mouthpiece, intubation device, resuscitation bag during CPR |
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Hand care under Standard Precautions ***
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- avoid artificial fingernails, which may separate from the real nail, leaving pockets for pathogen growth
- always wear gloves when treating a patient who places you at risk of contacting a bodily fluid, especially blood; and avoid contact with outer surface of the gloves when they are removed - wash your hands or use a hand rub before and after patient care |
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Sharps under Standard Precautions ***
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- dispose of all sharps in a puncture-proof container immediately after their use
- do not uncap or expose needles until they are needed - use caution when you handle and dispose of the item to avoid wounding yourself |
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Miscellaneous items to consider under Standard Precautions ***
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- avoid eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses in a patient care area
- avoid hand contact with mucous membranes (eyes, nose, mouth, ears) - handle all linen carefully, especially if soiled with pt's bodily fluids or waste; dispose of/transport it in the proper bag, hamper, or container - avoid unnecessary contact with a patient who places you at risk to contact a body fluid or waste product, especially blood - report incidents of contact with a patient's bodily fluids or waste products on an unprotected area of your body; seek immediate assistance if a direct blood-to-blood contact occurs between you and a patient |
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Transmission-based Isolation Precautions: ***
Contact Precautions |
- room will be private or cohort
- dedicated equipment used for patient care (e.g., stethoscope, thermometer, BP cuff, etc.) should remain in the room; if removed, it must be disinfected or placed in a bag labeled, "biohazard" - wash hands with chlorhexidine gluconate (CHG) antiseptic soap upon leaving the room - wear gloves on entering the room - wear a gown when having direct contact with the patient, environmental surfaces, or patient items and remove the gown before leaving the room |
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Transmission-based Isolation Precautions: ***
Droplet Precautions |
- room will be private
- patient transport will be done with a surgical mask on the patient, if possible - wash hands thoroughly on entering and leaving the room - mask is required when working within 3 feet of the patient |
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Transmission-based Isolation Precautions: ***
Airborne Precautions |
- room will be private with a negative air flow; door must remain closed
- patient transport will be done with a surgical mask on the patient, if possible - wash hands thoroughly on entering and leaving the room - an N-95 respirator (dust/mist respirator) must be worn when entering the room; it must fit snugly around the nose and face; discard it on leaving the room |
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What should be outside the room of a patient under Transmission-based Isolation?
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- cart, with directions for use, containing protective garments, biohazard bags, and other materials so they can be accessed prior to entering the room
- a color-coded card explaining the requirements for the amount and type of protection required |
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Isolation precautions: ***
Contact (clinical syndromes) |
- MRSA
- VISA (vancomycin-intermediate S. aureus) - VRE (vancomycin-resistant Enterococcus) - gram-negatives - uncontrolled diarrhea (C. difficile) - lice - scabies - impetigo |
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Isolation precautions: ***
Contact (room assignment) |
- private room or cohort patient with same infection
- dedicated equipment in room |
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Isolation precautions: ***
Contact (mask, gown, gloves?) |
- no mask
- yes gown, with direct contact with patient, environmental surfaces, or items in the patient's room - yes gloves, and CHG soap for hand washing |
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Isolation precautions: ***
Contact (patient transport/discontinuing isolation) |
- minimize transport as feasible
- clearing the patient from MRSA or VRE isolation should not be attempted if receiving antibiotics that treat that infection - VRE - discontinuation at the admission of initial diagnosis is discouraged; outpatient is preferred; three paired negative perirectal screens plus original site (if present on inguinal, axillary, or umbilical areas); pairs should be obtained at least 7 days apart - MRSA - three negative anterior nares screens plus original site (if present), obtained 24 hours apart |
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Isolation precautions: ***
Droplet (clinical syndromes) |
- mumps
- neisseria meningitidis - influenza - pneumonia - streptococcal pharyngitis |
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Isolation precautions: ***
Droplet (room assignment) |
- private room
- does not require negative air flow |
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Isolation precautions: ***
Droplet (mask, gown, gloves?) |
- yes mask when working within 3 feet of patient
- no gown - no gloves |
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Isolation precautions: ***
Droplet (patient transport, discontinuing isolation) |
- minimize transport of patient
- mask patient when transport is necessary - isolation for N. meningitidis may be discontinued after 24 hours of appropriate antibiotic therapy |
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Isolation precautions: ***
Airborne (clinical syndromes) |
- measles (pulmonary)
- tuberculosis |
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Isolation precautions: ***
Airborne (room assignment) |
- private room with negative air flow
- keep door closed (N-95) |
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Isolation precautions: ***
Airborne (mask, gown, gloves?) |
- yes mask - dust/mist mask
- no gown - no gloves |
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Isolation precautions: ***
Airborne (patient transport, discontinuing isolation) |
- minimize transport of patient
- mask patient when transport is necessary - isolation must be continued for mycobacterium tuberculosis until there are three negative AFB smears |
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Isolation precautions: ***
Airborne plus contact (clinical syndromes) |
- chickenpox, disseminated herpes zoster in immunocompromised hosts
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Isolation precautions: ***
Airborne plus contact (room assignment) |
- private room
- negative airflow - keep door closed |
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Isolation precautions: ***
Airborne plus contact (mask, gown, gloves) |
- yes mask - dust/mist mask (N-95)
- yes gown - yes gloves |
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Isolation precautions: ***
Airborne plus contact (patient transport, discontinuing isolation) |
- minimize transport of patient
- mask patient if transport is necessary - continue for duration of illness |
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Visitors of a patient in isolation must ______ before entering the room.
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report to the nurse's station
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List nine fundamentals of infection precautions ***
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- proper hand hygiene techniques and glove wearing
- use of masks, respiratory protection, eye protection, and eye shields (especially when fluid splashes or sprays are anticipated) - use of gowns and protective apparel - handling and disposal of linen and protection of laundry personnel - cleaning or disposal of eating utensils and dishes - routine and terminal cleaning of the patient's environment (use of disinfectants, consistent housekeeping activities in the patient's room and treatment areas) - patient placement (private room or with a person with the same disease) - protective transportation of an infected patient - use and care of patient care equipment and articles (disposal of sharps) |
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What is the difference between isolation and protective isolation?
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- isolation is to protect others
- protective isolation is to protect the patient (e.g., patients with extensive burns or open wounds, immunocompromised, or with systemic infections/sepsis) |
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What is the difference in donning and doffing of protective equipment for a patient in isolation vs. a patient in protective isolation?
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- when dealing with a patient in isolation, donning is not as important as doffing (you likely picked something up during treatment)
- when dealing with a patient in protective isolation, donning is more important than doffing, as the risk is greater of you giving them something than of them giving you something |
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What areas of your PPE are most likely contaminated post-treatment?
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- gloves
- sleeves - front of gown |
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Sterilization ***
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used to destroy all forms of microbial life, including high numbers of bacterial spores
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Methods of sterilization ***
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- steam under pressure or autoclaved
- gas (ethylene oxide) - dry heat - immersion in EPA- approved chemical sterilant for 6 – 10 hours (used only for instruments or equipment that cannot be sterilized with heat, such as those that penetrate skin) |
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What are the levels of disinfection? ***
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- high level
- intermediate level - low level |
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Describe a high level of disinfection ***
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destroys all forms of microbial life except high numbers of bacterial spores
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How is high-level disinfection carried out? ***
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- hot-water pasteurization (80° to 100°C) for 30 minutes, or
- EPA-approved sterilant chemical for 10 – 45 minutes - can be used for reusable items or items that come into contact with mucous membranes |
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Describe an intermediate level of disinfection. ***
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destroys most viruses, most fungi, vegetative bacteria, and the tuberculosis bacterium, but does not kill bacterial spores
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How is an intermediate level of disinfection carried out? ***
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- EPA-approved disinfectant chemical germicides labeled for TB; or
- household bleach approximately ¼ cup per gallon of water |
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Describe low-level disinfection. ***
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destroys most bacteria, some viruses and some fungi, but does not kill the TB bacterium or bacterial spores
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How is low-level disinfection carried out? ***
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EPA-approved disinfectants without label claim to kill TB, or spores
- used for routine housekeeping or soil removal without the presence of blood |
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What are the 11 guidelines for maintaining a sterile field? ***
(Be able to verbalize as many as possible during the skill check!) |
- the area of the field should be dry, as moisture can contain microorganisms that can seep through and contaminate your field
- do not talk, sneeze, cough or reach across your field, as air currents or moisture droplets can bring in pathogens - to reduce movement over the field, arrange items in order of use - do not turn your back on the field - do not leave the field unattended, even if covered with a sterile towel - a 1-inch border around the field is considered contaminated, as is anything that touches the border - do not allow sterile to nonsterile or nonsterile to sterile contact - the areas considered sterile on PPE are the gloves, sleeves, and front above the waist, unless otherwise contaminated - area below the field or your waist is nonsterile--don't reach in, leave what you drop - watch liquids; hold facing downward; if allowed to point up, risk sterile flowing into nonsterile, then back into sterile when pointed downward again - general housekeeping of the treatment area is important, as is good hand hygiene |
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Needles should not be uncapped until....
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they are used
(and should not be manipulated by hand when uncapped) |
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What is done with sharps after use?
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they are discarded into a puncture-proof container
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Hands should be washed immediately and thoroughly after they have been contaminated by blood, wound drainage, or other body fluids to which Standard Precautions apply, even if
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gloves are worn
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How is soiled linen handled?
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- as little as possible
- with minimal movement to prevent contamination of the air and persons who handle the linen - disposed of and transported in leak-proof bags that are clearly labeled to indicate they contain potentially contaminated linen - with reasonable care, even though risk of disease transmission from soiled linen contaminated with pathogenic microorganisms is negligible |
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How is protective clothing soiled with blood or other body fluids subject to Standard Precautions handled?
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- disposed of and transported in bags or other containers that are non-porous and leak proof
- persons bagging, transporting, or laundering the clothing should wear gloves |
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How are infected waste products (e.g., feces, urine, bulk blood, suctioned fluid) disposed of?
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- by carefully pouring into a drain or toilet connected to a sanitary sewer if permitted by institution and public health laws
- in some cases it is placed in plastic bags and sealed for transport - non-disposable bedpans must be cleaned thoroughly and sterilized between patients, and persons handling them should wear gown and gloves if soiling of handler's clothing is anticipated |
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What protective clothing should be made available to all caregivers who treat, transport, or handle items used for a patient whose condition requires Standard Precautions?
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- gloves
- gowns - masks - protective eyewear |
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What are the cons of using disposable gloves?
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- one size fits all
- don't conform to hands - can slip or come off |
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Regardless of type of glove used, when removing them, avoid....
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contact between the outside of the glove and the skin
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Situations warranting glove use
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- controlling bleeding
- venipuncture - oral or nasal suctioning - endotrachial intubation - changing contaminated dressing - handling or cleaning contaminated instruments or equipment |
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When should a gown, mask, and protective eyewear be worn?
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when there is:
- spurting blood - potential for splashing of blood or other bodily fluids containing blood |
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How are spills of body fluids handled?
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- removed as soon as possible
- surface cleaned with 1 part bleach (5.25% sodium hypochlorite) in 10 parts water, or with an EPA-approved hospital disinfectant - towels/linen used for cleanup also need to be disposed of properly - person cleaning up should wear gloves and possibly a gown |
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OSHA-mandated responsibilities for health care facilities:
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- educate employees on transmission and prevention of HBV and HIV
- provide safe and adequate PPE, and teach employees where it is and how to use it - teach employees about work practices used to prevent occupational transmission of disease, including but not limited to Standard Precautions, proper handling of specimens and linens, proper cleaning of body fluid spills, and proper waste disposal - provide proper containers for disposing of waste and sharps and teach employees the color-coding system used to distinguish infectious waste - offer HBV vaccine to employees at substantial risk of occupational exposure - provide education and follow-up care to employees exposed to communicable disease |
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What are the OSHA-required responsibilities for health care employees?
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- use PPE provided by the facility whenever anticipating contact with body fluids
- dispose of waste in proper containers, using proper color coding - dispose of sharps into proper containers without trying to recap, bend, break or otherwise manipulate them before disposal - keep work and patient care area clean - wash hands immediately after removing gloves and at all other times required by policy - immediately report any exposures such as needle sticks or blood splashes or personal illnesses to a supervisor and receive instruction about follow-up action |
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What is environmental disinfection?
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- used to clean and disinfect surfaces that have become soiled
- done with any cleaner or disinfectant intended for environmental use |
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What are environmental surfaces?
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- floors, woodwork
- mats or treatment table pads - countertops - walking aids - sliding or transfer boards - sinks |
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When liquids are used as cleaning agents, the person who uses them should....
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protect the skin from repeated or prolonged contact with the agent by wearing gloves and other PPE as necessary
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What should be done with an item prior to disinfection or sterilization?
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it should first be thoroughly cleaned to remove residual organic matter such as blood, excrement, or tissue
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For what types of conditions will a patient be placed in protective isolation?
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- extensive open burns/wounds
- immunocompromised - receiving chemotherapy or body irradiation |
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What is the most effective method of reducing pathogen transmission?
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proper hand hygiene
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Blanch
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to become pale
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Contracture
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shortening or tightening of the skin, muscle, fascia, or joint capsule that prevents normal movement or flexibility of the involved structure
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Ischemia
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deficiency of blood in a part because of functional constriction or actual obstruction of a blood vessel
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Maceration
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softening of a solid by soaking
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Necrosis
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morphological changes indicative of cell death
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Reverse T position
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position of the upper extremities when they are abducted to 90 degrees and externally rotated at the shoulders and with the elbows flexed to 90 degrees
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Seclusion
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involuntary confinement of a person in a room or area where the person is physically prevented from leaving
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Shear
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an applied force that tends to cause an opposite, but parallel, sliding motion of the planes of an object; stress is created to the object
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Spasticity
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continuous resistance to stretching by a muscle because of abnormally increased tension
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T position
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position of the upper extremities when they are abducted to 90 degrees and internally rotated at the shoulders and with the elbows flexed to 90 degrees
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List some of the areas susceptible to pressure injury. ***
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Supine
- occiput (tuberosity) - scapula (spine, inferior angle) - elbow (esp medial epicondyle) - sacrum - ischium - condyles (femoral/tibial) - heel (calcaneus) - posterior iliac crest - spine (vertebral spinous processes) - greater trochanter, head of fibula, lateral malleolus with excessive hip ER Prone - forehead - lateral ear - tip of acromion process - sternum - ASIS - anterior head of humerus - patella - ridge of tibia - dorsum of foot Wheelchair - scapula - vertebral spinous processes - sacrum - ischial tuberosities - popliteal surface - medial epicondyles - foot Side-lying - lateral ear - shoulder/acromion/head of humerus - lateral ribs - humeral epicondyles - ilium - greater trochanter of femur - condyles (femoral/tibial; lower lateral/medial; upper medial) - malleoli (lower lateral/medial; upper medial) - side of foot at 5th metatarsal |
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Although patient comfort is a consideration in positioning, caregivers must be aware that positions of comfort may....
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lead to development of ST contractures
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How often should a patient's position be changed?
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at least every 2 hours
(she said every 15 minutes) |
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Where does the greatest amount of pressure occur to tissues?
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over bony prominences
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Besides relieving pressure to skin and subcutaneous tissue what other systems are aided by changing the patient's position?
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- circulatory system
- neural system - lymphatic system |
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With what patients should caregivers ensure particular caution in positioning?
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patients with
- decreased sensation to pressure - inability to alter position independently and safely - minimal soft tissue over bony prominences - inability to express discomfort |
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How should a patient be positioned to ensure efficient function of body systems?
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- trunk, head, extremities supported and stabilized
- proper alignment of appendicular and axial skeletal segments |
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Before initiating treatment, caregivers should determine:
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- how position may affect body mechanics
- the best position to enable treatment effectively, efficiently, and safely |
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Areas susceptible to pressure injuries in supine position ***
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Head and trunk:
- occipital tuberosity - spine of scapula - inferior angle of scapula - vertebral spinous processes - posterior iliac crest - sacrum Upper extremities: - medial epicondyle of humerus Lower extremities: - posterior calcaneus - greater trochanter - head of fibula - lateral malleolus |
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Areas susceptible to pressure injuries in prone position ***
(uncommonly used) |
Head and trunk:
- forehead - lateral ear - tip of acromion process - sternum - anterosuperior iliac spine (ASIS) Upper extremities: - anterior head of humerus Lower extremities: - patella - ridge of tibia - dorsum of foot |
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Areas susceptible to pressure injuries in side-lying position ***
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LOWERMOST EXTREMITY (on the bottom/bed)
Head and trunk: - lateral ear - lateral acromion process - lateral ribs Upper extremity: - lateral head of humerus - medial or lateral epicondyle of humerus Lower extremity: - greater trochanter of femur - medial and lateral condyles of femur - malleoli of fibula and tibia UPPER EXTREMITY Head and trunk: - none noted Upper extremity: - medial epicondyle of humerus (if resting on hard surface) Lower extremity: - medial condyle of femur - malleolus of tibia |
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Areas susceptible to pressure injuries in sitting position ***
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Head and trunk:
- scapular spine - vertebral spinous processes - ischial tuberosities - sacrum Upper extremities: - medial epicondyle of humerus (if resting on hard surface) Lower extremities: - none given in chart, but popliteal surface and foot highlighted in picture |
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What should the caregiver ensure regarding linen and clothing beneath the patient? Why?
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that there are no folds or wrinkles
to avoid increased skin pressure that may lead to tissue damage |
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What is the rationale for proper positioning? ***
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- to prevent ST injury and pressure and joint contracture
- provide support and stability of the trunk and extremities - provide access and exposure to areas to be treated - promote efficient function of patient's body systems - relieve excessive, prolonged pressure to soft tissue, bony prominences, and circulatory and neurological structures - provide patient comfort |
|
|
|
What patients require special attention for positioning?
|
patients with
- decreased sensation/paralysis - decreased skin integrity - impaired circulation - predisposition to contracture development - poor nutrition |
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Patients requiring special attention for positioning should have their skin inspected before and immediately after treatment for...
|
- red areas (indicate pressure)
- pale/blanched areas (possibly indicating severe, dangerous pressure) - edema/swelling (pressure to localized area of ST, especially over a bony prominence, produces local ischemia which can lead to tissue necrosis over time) - patient complaints of numbness or tingling (especially over bony prominences) |
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|
Restraints are used
|
- only short-term
- for protection (pt or others) - with pt consent and physician's order - only when less-restrictive interventions have been tried and found ineffective |
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Physical or drug-induced restraints, along with seclusion must be:
|
prescribed by a physician
|
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A restrained patient must be monitored at least
|
every 2 hours
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Supports for supine position
|
- under head, without causing excessive neck flexion or scapular abduction
- at popliteal space, but be aware that this encourages hip and knee flexion and can cause contractures of hip flexors (iliopsoas) and knee flexors (hamstrings) - under ankles, to relieve calcaneal pressure, but without hyperextending knee |
|
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Supports for prone position
(uncommonly used) |
- under patient's head (forehead) unless head is turned to left or right
- under lower abdomen to reduce lumbar lordosis (if necessary/desired) - under each shoulder to protect head of humerus and adduct scapulae - under anterior ankles to relieve stress on hamstrings; aware that this causes knee flexion and could lead to contractures of hamstrings |
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Supports for side-lying position
|
- with LE flexed at knees and hips, uppermost LE supported on 1-2 pillows and slightly forward of lowermost
- 1-2 pillows under pt's head - folded pillows in front of trunk to support uppermost UE and prevent rolling forward; in back of trunk to prevent rolling backward |
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Supports for sitting position
|
- pillow behind pt at back
- UE can be supported by pillows - distal posterior thigh should be free of pressure from edge of chair/wheelchair - feet should be supported |
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In general, patients who
- are inactive - have restricted mobility - are unable to alter body positions should not be positioned for an extended period (>30 mins) in any position that causes.... |
- excessive rotation/bending of the spine
- bilateral/unilateral scapular abduction or a forward head position - compression of thorax/chest - plantar flexion - hip/knee flexion - knee hyperextension - adduction and IR of the GH joint - elbow/wrist/finger flexion - hip adduction or IR/ER because these positions promote excessive stress or strain to structures and may promote development of ST contracture or patient discomfort |
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A reddened or blanched area that does not return to a normal appearance within ____ after treatment must be monitored.
|
an hour
(and the position used that caused it should be discontinued) |
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Common ST contracture sites related to prolonged positioning: supine ***
|
- hip/knee flexors
- ankle plantar flexors - shoulder extensors, adductors and IRs - hip ERs |
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|
Common ST contracture sites related to prolonged positioning: prone ***
|
- ankle plantar flexors
- shoulder extensors, adductors and IRs/ERs - neck rotators, left or right |
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|
Common ST contracture sites related to prolonged positioning: side lying ***
|
- hip and knee flexors
- hip adductors and IRs - shoulder adductors and IRs |
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|
Common ST contracture sites related to prolonged positioning: sitting ***
|
- hip and knee flexors
- hip adductors and IRs - shoulder adductors, extensors, and IRs |
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List the given precautions for patient positioning ***
|
- avoid clothing or linen folds beneath patient
- avoid excessive, prolonged pressure to ST and circulatory and neurological structures - observe skin color over bony prominences before, during, and after treatment - protect bony prominences from excessive and prolonged pressure - avoid positioning the patient's extremities beyond the supportive surface - use additional caution when positioning patients who are mentally incompetent or confused, paralyzed, comatose, very young or elderly, or lacking normal circulation/breathing or sensation |
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What is the best way to avoid contractures? ***
|
get the patient walking (if possible) as ambulation addresses most, if not all, of the most common sites of contracture
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In addition to redness/blanching, what is another indicator of abnormality in tissue? ***
|
temperature difference
(e.g., right malleolus colder than left) |
|
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What are the chief causes of pressure ulcers? ***
|
- pressure (to soft tissue that exceeds the normal capillary pressure of local circulation)
- shear (to superficial skin; actually starts killing the tissue under the skin first) - friction (to superficial skin) |
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|
If the foot cannot be dorsiflexed to 0 degrees... ***
|
the Achilles tendon and plantar metatarsal heads are at risk for increased soft tissue pressure and ulcer formation
|
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|
Besides pressure, shear, and friction, what other risk factors contribute to formation of pressure injuries? ***
|
- inadequate/improper nutrition
- inadequate fluid intake - insensate body areas, especially those insensitive to pressure - persistent incontinence leading to skin irritation, maceration, and/or breakdown - metabolic or systemic disorders or diseases, especially diabetes - persistent use of tobacco products (as nicotine is a vasoconstrictor) |
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What are the guidelines for pressure ulcer intervention and management? ***
|
- plan and follow a program designed to prevent the development of pressure ulcers, especially for persons who demonstrate a high risk
- provide pressure relief or reduction to body areas susceptible to ulcer development - develop and follow a schedule to alter the patient's position - initiate mobility activities that are possible, safe, and appropriate; include bed, wheelchair, and ambulation activities (shear forces must be avoided) - develop and follow a schedule to observe, evaluate, remove, and apply dressings that is appropriate for the patient and personnel involved - perform wound and skin cleansing; avoid the use of toxic agents, including many types of soaps, hydrogen peroxide, and povidone-iodine (Betadine) - perform debridement of necrotic tissue, as necessary, to promote healing - rinse the ulcer with a sterile saline solution with an appropriate pressure (2-10 psi) at the time of dressing changes - perform consistent and thorough perineal care, especially when the patient is incontinent - determine the nutritional and fluid intake needs of the patient; establish an appropriate diet and feeding schedule to meet the needs - provide education to all caregivers involved with the patient's care, including the patient's family members; include information on prevention, care, and management |
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How is the Braden Scale designed to detect risks for possible pressure injury? ***
(p. 326) |
See next slide and P. 326, Appendix 11-1
Braden Scale Interpretation: Scale of 1-4* for each of 6 variables; 1 is highest risk (one variable is only 1-3, thus max of 23 points) Score range: 6-23 < 12: high risk 12-14: moderate risk 15-16: mild risk 17-18: low risk |
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|
What variables does the Braden Scale assess? ***
|
- sensory perception
- moisture - activity - mobility - nutrition - friction and shear (1-3) |
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What is considered to be the best means to control nosocomial infections (a.k.a. healthcare-associated infections)?
|
Standard Precautions
|
|
|
|
Three layers of the skin ***
|
- epidermis
- dermis - subcutaneous |
|
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|
What is the only layer of skin that will regenerate? ***
|
epidermis
the dermis and subcutaneous layers regenerate as granulation tissue |
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Will skin heal to its original tensile strength? ***
|
- the epidermis MAY heal to 100%, but aging lessens this likelihood
- granulation tissue heals only to about 80% of the strength of normal healthy tissue--it is never as good as new |
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|
What are the basic goals of wound care? ***
|
- protect wound from further trauma
- prevent infection (use the right dressings) - promote healing (modalities can increase healing to 35-50% per week) - promote formation of healthy scar tissue - prevention |
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|
How do PTAs stage wounds? ***
|
we do not stage and cannot downstage wounds, this is a nursing responsibility
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How many stages of pressure ulcers are there? ***
|
3 (4?)
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|
Describe a stage 1 pressure ulcer. ***
|
- non-blanchable erythema of intact skin that persists for greater than 30 min
- darker skin displays discoloration, warmth, edema, and indurations (hardness) |
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What is important to remember about the dermal and subcutaneous layers of skin in the elderly? ***
|
they are thinner, and with less padding the bony prominences can do a lot of damage very quickly (can go from normal to stage 1 in 30 minutes)
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|
Describe a stage 2 pressure ulcer. ***
|
- partial thickness skin loss involving epidermis and/ or dermis
- presents as blister or very shallow crater - skin is now open and infection, maceration, etc. are possible |
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What is important to remember about blisters? ***
|
- if intact, leave them alone, the body is good at healing itself
- if broken, need treatment |
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Describe a stage 3 pressure ulcer. ***
|
- full thickness skin loss involving damage or necrosis of subcutaneous tissue
- presents as deep crater |
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Describe a stage 4 pressure ulcer. ***
|
- full thickness skin loss with extensive destruction, tissue necrosis, or damage to the muscle, bone or exposure of the joint
- the bone may be covered by biofilm, slough, etc. and you can only tell by probing with Q-tip (bone feels "scratchy" and tendon/ligament is smooth and slippery) |
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What is the periwound? ***
|
the surrounding area outside the wound bed
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|
What is eschar? ***
|
dry, dark brown, fibrous tissue
(looks like beef jerky) |
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What is slough? ***
|
soft, stringy, light tan/yellow/green tissue
(looks like cheese on pizza) |
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What is induration? ***
|
hard tissue surrounding the wound that has been there a long time
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What is ebobyli? ***
|
when the edge tissue of the wound curls under
can be hard |
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What is hypergranulation? ***
|
too much tissue is produced, to where it almost mounds in the middle
epithelial tissue will not grow over it and it must be removed (debrided) |
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What is maceration? ***
|
- too much drainage
- tissue around edges is white and moist |
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What is the ideal appearance of granulation tissue? ***
|
beefy red, like ground beef
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|
What is the first phase of wound healing? ***
|
inflammatory (acute) phase
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|
|
Describe the inflammatory phase of wound healing. ***
|
- stage lasts 4-7 days in healthy person
- purpose: to decrease tissue damage, remove or clean dead cells begin to repair tissues - vasodilation 1)Increase erythema 2)Increase drainage - thin if not infected, thick if infected 3)Increase pain 4)Increase warmth - infected wound-greater than 100,000 organisms per gram of tissue can often tell infection by smell--earthy, pungent |
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|
What is the second phase of wound healing? ***
|
proliferative (subacute) phase
|
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|
|
Describe the proliferative phase of wound healing. ***
|
- 4-21 days in healthy individual
- establishment of collagen matrix - growth of granulation tissue - epithelial cells migrate across a warm moist bed causing contraction of wound |
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|
What is hemosiderin staining? ***
|
when blood has pooled for a while and the iron in it leaks into the tissue producing a red/brown stain
|
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|
Presentation of infected vs. uninfected wounds ***
|
- thin discharge - not infected; thick discharge - infected
- smell disappears with wound cleaning - not infected; smell remains after cleaning - infected - if very bloody, almost always infected |
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|
What does a wound in the chronic inflammatory state look like? ***
|
pale and flat with no texture
|
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|
What is the third phase of wound healing? ***
|
remodeling/maturation or
epithelialization phase |
|
|
|
Describe the third phase of wound healing. ***
|
- day 21 to 2 years
- organization of scar tissue; initially red due to increase capillaries - as capillaries decrease, scar tissue contracts and pales Remember : - process can go for several years depending on size of wound scar - avoid sun expose due to vulnerability of pigment - scar tissue only 80% of original tensile strength (so don't let the patient plop right back down on the ischial tuberosities you just helped heal) |
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|
What typically happens with wounds of the heels as they heal? ***
|
- they tend to get fibrous edges
- edges need to be rubbed a bit to keep them raw and actively healing |
|
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|
Describe arterial insufficiency wounds. ***
|
- often brought on by arteriosclerosis
- blood cannot reach extremities, thus skin breaks down/dies typically located: - between, on, around the toes - phalangeal heads - lateral malleolus appearance: - “punched out” wound edges (as if made by a cookie cutter) - dependent rubor; purple extremities - deep - minimal exudate - frequently painful |
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|
Describe venous insufficiency wounds. ***
|
- brought on by valvular incompetence
- blood can get there, but cannot get back out location: - gator region - medial aspect of lower leg/ankle - superior to med malleolus appearance: - irregular wound edges - shallow - moderate to heavy exudate (because of all the pooling fluids) - not usually painful |
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|
Describe diabetic ulcers ***
|
- damage to sensory, motor, and autonomic nerves of lower extremity
location: - plantar aspect of foot - metatarsal heads - heels appearance: - even, well-defined margins - variable depth - variable exudate - painless - usually callous (edges harden very quickly) |
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|
List 12 factors that affect wound healing. ***
|
- location (central wounds heal better than more distal wounds)
- size (smaller heal better) - age (younger people heal better) - nutrition/hydration - skin holds in fluid; when opened--it leaks - metabolic diseases/illness (e.g., diabetes, PVD) - systemic medications - vascular insufficiencies - immunosuppression - neurological factors - SCI, MS, Parkinson's, Huntington's Chorea - psychological factors - mobility - lab reports |
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|
How are wounds assessed? ***
|
- phase of wound healing (wound HAS to go through all three phases of healing--sometimes simultaneously)
- size of wound ---- L x W using 12 o’clock method (use cm, wound edge to edge, not periwound) ---- depth (can do 12-3, 3-6, 6-9, 9-12) ---- plastic measuring tool ---- use of Q-tip - % of necrotic, granulation, and epithelial tissues (slough, eschar, bone) - any undermining or tunneling - odor - color - exudate -- color, amount, consistency - surrounding tissue (periwound) - wound healing |
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|
Why is it important to look at/understand the patient's lab work? ***
|
- to see their nutrition levels
- important because, for example, if there is not enough circulating protein (albumin) in the system, the wound WILL NOT heal no matter what you do |
|
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|
Types of wound drainage ***
|
- serous - clear light color, watery consistency
- sanguineous/bloody - red color, watery consistency - serosanguineous - light red to pink, watery consistency - seropurulent - cloudy yellow to tan color, watery to thicker consistency - purulent/pus - yellow, tan, green even bluish in color, thick opaque consistency |
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|
What are the treatment goals for pressure ulcers? ***
|
- relief of pressure
- pressure relieving devices - bed, wheelchair positioning - transfer techniques (let patient do as much as possible) - range of motion exercises - appropriate mobility program (adjust as needed) - education of caregivers |
|
|
|
Treatments for wounds ***
|
- debridement
- high voltage pulsed current (e-stim can help make significant progress--30-50% per week) - ultrasound - diathermy (excellent for all phases and to open blood flow in arteries) - laser - wound vac (this is nursing's responsibility) - hyperbaric oxygen - whirlpool (out of favor due to contamination no matter how you clean it) - wet to dry (for a chronic, stubborn wound; dress it to wick moisture, dressing then dries and sticks, pulling off the wound bed and taking wound back to inflammatory phase) |
|
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|
Upon what does choice of dressing for a wound depend? ***
|
- phase of healing
- depth - drainage |
|
|
|
What types of wound dressings are available? ***
|
- gauze
- semi permeable - semi permeable hydrogels - semi permeable hydrocolloids - hydrocolloid absorptive - occlusive |
|
|
|
Medications available for wound care ***
|
topical
- accuzyne (debrides, but too expensive) - panafil (stimulates granulation tissue; turns dead tissue green for easy debridement; too expensive) - santyl (polysporin) (slow debrider) others - xenaderm (short-term use or it toughens tissue) - iodasorb (antiseptic; jump starts stubborn wounds back into inflammatory phase) - lidocain 5% (analgesic; by prescription at 5%, OTC at 1%) |
|
|
|
How should a wound be packed? ***
|
lightly
if too tightly packed, you can kill the granulation tissue |
|
|
|
What is important to remember about wound care? ***
|
- read evaluation thoroughly
- work closely with other personnel (Dr., CNA, OT/COTA, Dietitian, NS ) - educate on prevention - know what you can and cannot do - do not order expensive dressing if less will do |
|
|
|
Autolysis
|
disintegration of cells or tissues by the enzymes of the body or cellular components in wound fluid
|
|
|
|
Debridement
|
removal of devitalized tissues from or adjacent to a traumatic or infected lesion to expose healthy tissue
|
|
|
|
Epithelialization
|
healing by the growth of epithelium over a denuded surface
|
|
|
|
Eschar
|
a dry scab; devitalized tissue
|
|
|
|
Exudate
|
a fluid with a high composition of protein and cellular debris that has escaped from blood vessels and is deposited in tissues or on tissue surfaces
|
|
|
|
Granulation
|
any granular material on the surface of a tissue, membrane, or organ
|
|
|
|
Induration
|
the quality of being hard; abnormal firmness of tissue with a definite margin
|
|
|
|
Lymphedema
|
a functional overload of the lymphatic system in which lymph volume exceeds transport capabilities resulting in obstructed lymph flow
|
|
|
|
Maceration
|
the sofenting of a solid or tissue by soaking
|
|
|
|
Necrosis
|
the morphological changes indicative of cell death
|
|
|
|
Slough
|
a mass of dead tissue in, or cast out from, living tissue
|
|
|
|
Sterile
|
free from any microorganisms; aseptic
|
|
|
|
Ulcer
|
a local defect or excavation of the surface of an organ or tissue produced by sloughing of necrotic inflammatory tissue
|
|
|
|
Critical components of wound care
|
- protective positioning
- nursing procedures - topical/systemic medications - proper nutrition/hydration - proper skin care |
|
|
|
Caregiver must be able to recognize in a wound...
|
- type of wound
- phase of healing - factors that affect healing |
|
|
|
Edema occurs when what kind of vessels are impaired
|
venous or lymphatic
|
|
|
|
What is
- primary lymphedema? - secondary lymphedema? |
primary is congenital, and usually in LE
secondary is caused by - surgical removal of lymph nodes, - tumor invasion of lymph nodes, - injury or infection to the lymph drainage system, or - radiation therapy which can damage lymph channels |
|
|
|
Where is lymphedema most commonly found?
|
in the extremities
|
|
|
|
The sterile field is a form of _____ _____ designed to keep the area free from pathogens.
|
surgical asepsis
|
|
|
|
What are the four rules of asepsis?
|
- know which items are sterile
- know which items are not sterile - separate sterile items from nonsterile items - if a sterile item becomes contaminated, the situation must be remedied immediately |
|
|
|
What is the remedy for contamination when a nonsterile item contacts a sterile item?
|
discard the contaminated item and reestablish sterile field
|
|
|
|
For what should the outer packages of prepackaged sterile items be checked?
|
- expiration date
- intact seal - no evidence of water damage (contamination) |
|
|
|
If you have any question as to whether an item is nonsterile, consider it...
|
contaminated and do not use it
|
|
|
|
Describe the inflammatory phase of wound healing
|
- body's initial local defense
- begins immediately after injury or trauma - initiates wound healing - functions to limit tissue damage, remove injured or damaged cells, and repair injured tissue - three stages ---- vascular ---- exudate ---- reparative |
|
|
|
Describe the vascular stage of the inflammatory phase of wound healing
|
- hyperemia due to change in cellular filtration pressures and increase in permeability of cells
- edema, pain, erythema, warmth |
|
|
|
Describe the exudate stage of the inflammatory phase of wound healing
|
- several appearances
---- serous (pale and clear) ---- purulent (pus) ---- fibrinous (clotting) ---- hemorrhagic (bleeding) - fluid passes through walls of vessels into adjacent tissues to deposit fibrins and leukocytes |
|
|
|
Describe the reparative stage of the inflammatory phase of wound healing
|
- damaged cells are replaced and true wound healing begins
- phagocytosis removes damaged cells |
|
|
|
Describe the proliferative phase of wound healing
|
- overlaps inflammatory phase
- granulation (fibroblasts, collagen; capillary buds develop at edges and advance to center of wound) - contraction - epithelialization (requires moist surface) |
|
|
|
Describe the remodeling phase of wound healing
|
- overlaps proliferative phase
- organization of collagen into more definitive pattern - increase in tensile strength (but only to 80% of original tissue) - lasts 3 weeks to 2 years |
|
|
|
What is healing by
- primary intention? - secondary intention? |
- preferred method; edges of wound are closely related, or approximated by sutures, staples or other means and heal with less infection and scarring in a shorter time
- wounds that are large, have retracted edges, or large amounts of tissue loss; heal by gradual filling with granulation material; infect easily, scar excessively, and take longer to heal; better able to heal with grafts, etc. |
|
|
|
Basic goals of wound care and management
|
- protect wound and surrounding tissue from additional trauma
- reduce strain on tissues near wound - protect tissue near wound from mechanical stress or movement - reduce number of pathogenic microorganisms in and around wound - expedite healing process - decrease or reduce formation of scar tissue |
|
|
|
Extrinsic factors affecting wound healing
|
- pressure on soft tissue over bony prominences
- shear forces on the skin, especially at heels and sacrum - maceration of skin - infection, presence of high number of pathogens in wound or surrounding tissue - medications (enhance or delay) - reduced activity/prolonged immobility |
|
|
|
Intrinsic factors affecting wound healing
|
- size, extent, location, type of wound and distance between edges
- adequacy of blood flow to wound - condition of the skin - general health of patient - nutritional/hydration status - body build and composition |
|
|
|
Factors that contribute to the risk of pressure ulcers
|
- age
- body condition and composition - disease state - circulatory or metabolic disorders - mobility of patient |
|
|
|
What two primary factors can result in development of a pressure ulcer?
|
- pressure to soft tissue that exceeds normal capillary pressure of local circulation (capillaries are compressed and can no longer bring in oxygen and nutrients and remove waste)
- friction or shear forces to superficial skin |
|
|
|
When capillaries are compressed over time, they become ______.
|
occluded
(and ischemia occurs, as well as the potential for tissue necrosis) |
|
|
|
When are shear forces likely to occur?
|
- position changes
- transfers - during exercise activities |
|
|
|
Shear force from the caregiver's hand or bed linen may produce....
|
friction to the skin, which causes surface heat and erosion of the epidermis
|
|
|
|
Every patient who is admitted to a health care facility or treated at home should be assessed to determine...
|
potential risk for development of a pressure ulcer
(e.g., with Braden Scale or PUSH tool) |
|
|
|
If patient is determined to be at increased risk of developing a pressure ulcer, a ____ ____ should be implemented immediately.
|
prevention program
and all persons having contact with the patient should be considered members of the prevention team |
|
|
|
How is pressure over bony prominences relieved?
|
- elevating the area
- changing position frequently - positioning so area is not in contact with source of pressure - separating bony prominences - pressure-reduction devices |
|
|
|
Wound management techniques
|
- remove pressure
- keep clean - avoid friction and shear - maintain moist wound bed - protect surrounding tissue - observe for infection - absorb exudate - soften and remove eschar, necrotic tissue - contain any infection |
|
|
|
Stages of development of pressure ulcer are progressive, but does the healing process follow regressively?
|
no
(e.g., a stage III pressure ulcer will continue to be classified as a stage III, but percentage of wound that has healed is reported, or a measurement and description of the open area are used to indicated improvement/healing) |
|
|
|
If the depth of a wound cannot be measured or visualized (e.g., wound covered with eschar or deep tissue injury with intact skin over) it cannot be...
|
staged
the eschar-covered wound must be debrided |
|
|
|
"Partial thickness" indicates a pressure ulcer has penetrated....
|
- the epidermis and upper dermis, but has not reached the subcutaneous tissue
- wound is considered to be superficial |
|
|
|
"Full thickness" indicates a pressure ulcer has penetrated....
|
- the epidermis, the entire dermis, and that subcutaneous tissues are involved
- joint tissue, fascia, and/or bone may be affected - wound is considered to be deep |
|
|
|
How are wounds measured?
|
- in centimeters
- overlay oriented with top toward patient's head - length along 12-6 o'clock line - width along 9-3 o'clock line - depth, undermining, tunneling with swab - undermining and tunneling areas described by clock position |
|
|
|
What type of gloves are used for wound measurement?
|
clean, nonsterile
nonsterile, really? |
|
|
|
How may debridement be carried out?
|
- sharp instrument (quickest)
- mechanically (pressure irrigation/pulsed lavage, removing dressings, hydrotherapy, e-stim) - chemically - autolysis (enzymes) |
|
|
|
What lab values should be monitored in a wound patient?
|
- prealbumin
- albumin - total protein |
|
|
|
Purpose of dressings
|
- protect wound
- assist healing - reduce infection/contamination - remove exudates and toxic waste when dressing is removed |
|
|
|
What aspects of a pressure ulcer should be documented?
|
- site or location
- stage - size and total surface area - depth - evidence/extent of tunnels or undermining (width and length) - percentage of color, new skin - composition of ulcer (granulation, epithelialization) - edema or induration - type and amount of exudate (viscosity, color, consistency) - odor (after cleaning) - signs of inflammation - condition of surrounding skin - increase in pain |
|
|
|
Most common site of venous insufficiency wounds
|
medial malleoli
|
|
|
|
Dressing layers and
bandage layers |
- topical medication
- nonabsorbent material over medication - cotton gauze pad - absorbent material if excessive drainage - roller gauze, etc. - elastic wrap |
|
|
|
Functions of a dressing
|
- prevent additional wound contamination
- keep microorganisms in the wound from infecting other sites - prevent further injury - pressure to control hemorrhage - absorb wound drainage - assist healing |
|
|
|
Functions of a bandage
|
- keep dressing in place
- barrier between dressing and environment - external pressure to control swelling - support or stabilize an area - hold splint in place - assist dressing in performing its function |
|
|
|
How is a dressing removed?
|
- assume contaminated and use clean technique with nonsterile gloves (nonsterile--really?) for self-protection
|
|
|
|
Once the (nonsterile) gloved hand has touched the dressing or wound, it must not touch
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any other object, especially patient's or caregiver's skin, the clean (sterile) dressing, or any other object in the area
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Briefly describe rubor of dependency test.
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- note color of plantar surface of foot in supine patient
- elevate LE 45-60 degrees for 1 minute and note any color change - return LE to level and check plantar color again |
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Briefly describe claudication test
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patient walks on level treadmill at 1 mph until claudication occurs, record time elapsed when calf pain prevents continuing to walk
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How is a dressing that adheres to the wound removed?
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soaking helps to soften the hardened exudate
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How much bleeding is acceptable during debridement?
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the wound should not bleed during or after debridement
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When applying medication to a wound, what care must be taken with the applicator and medication?
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- sterile applicator must not contact nonsterile exterior of medication tube or jar
- care must be taken not to contaminate contents of tube or jar of medication with applicator once it has contacted the patient - use a new swab or gauze each time medication is obtained from tube or jar |
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How is first layer of dressing applied?
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with sterile gloves or forceps
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Once the initial layer of dressing has been applied, how are the upper layers applied?
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do not need to use sterile technique
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Indicators of improperly applied bandage
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- segment distal to bandage turns excessively pale, blue, or red
(too tight, affecting local circulation) - pt complains of pain, numbness, tingling, or burning (too tight, affecting neural receptors) - exposed distal segment feels cold compared with similar, opposite segment (too tight, constricting flow of arterial blood) - edema develops distal to bandage (too tight, constricting lymphatic and/or venous circulation) - bandage changes position (usually too loose) |
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In a figure-8 wrap for strain or sprain how is the limb positioned?
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wrap so that the injured muscles are shortened so you don't cause a contracture
(e.g., if you have a sprained ankle on the outside make sure to tighten it so that the foot is in dorsiflexion & eversion) |
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Where does the figure-8 wrap start and finish?
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wrap distal to proximal so you do not cause a tourniquet
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For what is a spiral wrap used?
How is the patient's foot positioned and why? |
if the pt has an ulcer on the foot
- you do the wound care then when wrapping you place the pt's foot in dorsiflexion, again so you don't cause a contracture that forces the foot into plantar flexion - this also makes sure that the wrap isn't too tight - this is a gauze-type wrapping that should not be tight, just snug enough to not slide off the foot |
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In a figure-8 wrap for strain or sprain how is the limb positioned?
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wrap so that the injured muscles are shortened so you don't cause a contracture
(e.g., if you have a sprained ankle on the outside make sure to tighten it so that the foot is in dorsiflexion & eversion) |
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Where does the figure-8 wrap start and finish?
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wrap distal to proximal so you do not cause a tourniquet
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