11/19/2011 9:55:00 AM N193 Environmental Safety/Surgical Asepsis I Definitions: A. Medical Asepsis: How to accomplish? B. Surgical Asepsis: How to accomplish?

C. Sterile Field: How to accomplish? D. When To Use Sterile Technique? 1) 2) 3) 4) 5) 6) II. Principles of Surgical Asepsis (Module p. 177) III. Wounds A. Classification (review functions of skin, skin assessment, common skin findings, transcultural assessment, and aging skin changes (Ignatavicious and Eliopoulous) 1. a) intentional b) unintentional a) open b) closed

2.

3. Contamination a) clean b) clean/contaminatedc) contaminatedd) dirty/infected4. Thickness a) partial-thicknessb) full-thicknessTerms describing wounds: (review independently in Kozier) IncisedContusedAbradedPunctureLacerationPenetrating5. RYB Color Code VS. Staging a) RYB guides interventions b) Based on color, not size or depth c) CODE 1.Red: a) b) c) 2.Yellow: a) b) c)

3.Black a) b) c) d) Stages IIIIIIIV6. Wound Drainage 1. serous: a) b) 2. a) b) 3. a) b) 4. a) b) sanguineous: purulent:

serosanguineous:

7. Wound Healing Types primary intention 1) 2)

secondary intention 1) 2) 3) 4) 5) 6) Tissue Regeneration a) Inflammatory phase 1) hemostasis 2) phagocytosis b) Proliferative Stage 1) fibrolysis 2) capillary growth via fibrin network 3) epithelialization occurs if would stays moist 4) eschar c) Maturation phase (Day 22-2years) 1) collagen fibers reorganize-----=scar 2) stronger than skin but less elastic 8. Factors affecting Wound Healing age & development nutrition lifestyle medications infection Geriatric wound healing 1) 2) 3) 4) 5) Healthy wounds

9. Complications of Wound Healing Hemorrhage: persistent bleeding, dislodged clot, external -internal swelling, distention, may have hypovolemic shock Hematoma: blood clot beneath skin at wound site if large, pressure on blood vessels, tissue perfusion decreased if in blood vessel, can embolize Infection: most likely 2-11days post-op unintentional contaminated wounds Dehiscence: partial or total rupture of wound -obesity, poor nutrition, S/Sx: medical emergency unexplained fever wound pain Gush of serosanguineous fluids Nursing 1) stay with patient. Call DR 2) cover incision with sterile towels soaked with NS Evisceration: protrusion of internal viscera through incision same causes and SX as dehiscence except viscera visible cover with sterile towels soaked with NS needs surgical repair Fistula: abn passage between 2 organs or between organ and outside of body -needs drain, packing -sometimes surgical repair IV. NURSING PROCESS Wound Assessment Subjective: Objective:

untreated wounds 1) assess bleeding, size, depth, foreign bodies 2) assess pt condition, associated injuries cover with sterile dsg; apply pressure to approximate edges treated wounds 1) appearance/location, size, depth, color/staging a b. c. 2) drainage a. b. c. 3) swelling a. b. 4) drains & tubes: penrose, t-tube, hemovac, foley a. labs: WBC, coagulation, C & S, serum protein, H & H document site, stage, shape, exudate, surrounding tissue, edges Nursing Diagnoses Skin Integrity, Impaired R/T Incisional trauma Delayed Surgical Recovery R/T compromised nutritional status ? ? Plan promote wound healing prevent infection & other complications promote health & self-care ? ?

Implementation 1. Promote healing a) maintain good blood supply keep clean and free from body secretions consult with ET when drainage severe shorten penrose drains maintain vacuum suction on Hemovac/JP when ordered debride and irrigate (need order) change wet dressings prevent stress on wound (gaseous distention, vomiting, coughing) maintain good nutrition & electrolyte balance 2. Prevent Complications: infection and hemorrhage use sterile technique pressure dressings 3. Gerontologic Considerations be very gentle expect healing to take longer 4. Open VS. Closed Wound Care Open: no dressing expose to air -> drier less bacterial growth-> decreased risk of infection less irritation from friction Closed: dressing absorbs dge, debrides wound protects from environmental contamination 3) 4) 5) covers disfigurements/protect from pt view Cleansing Wounds removal of debris, microorganisms use NS unless order for antimicrobial solution principle: clean from clean to dirty prevents organisms into wound top to bottom outward laterally from incision

circular from center of wound outward new sterile swab for each stroke if incision & drain: clean incision 1st, then drain Dressings types of materials dry sterile gauze (4x4, 4x8), drain sponge-cover wound abd pads-absorb, cover, and hold gauze telfa pads synthetic a) semi-permeable b) hydrocolloids decision about type & amt based on location, size, type exudate infection, debridement frequency, difficulty,cost, pt comfort Purposes dry: wet to dry: a) debrides necrotic tissue when removed b) change q6-8 or as ordered 3) wet to damp 4) wet to wet a) change q4h b) crate warm dark, damp environ->incd risk of infection 5) synthetic wound barriers a) b) c) In Kozier, look over before lab. We will go over in detail SKT c) Procedure 1) think procedure through a) ask what supplies are needed -peek under corner of dsg -may need to medicate 1st, or void -remove tape carefully d) e) f)

-remove outer dsg with clean gloves a) b) c) d) i) ii) iii) -open sterile supplies in reverse order -put on sterile gloves, designate clean vs. sterile hand -clean and treat wound a) b) c) d) -place new dsg on wound -tape a) type: i) ii) iii) iv) v) b) tape across body or in direction of creases, oppose body movement c)document d) site, size, shape, exudate, surrounding skin, stage

Wound drains & Suction Purposes drain exudate from wound remove dead space promote healing types open: penrose a) b) c) d)

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closed: hemovac & JP maintain suction unless order not to Wound Irrigation and Packing a) b) c) V. HEAT & COLD THERAPY Effects Heat a) b) c) d) Cold a) b) c) d) Rebound Phenomenon: occurs at time of max therapeutic effect (usually 15-20 min), then opposite effect starts: can cause damage thermal therapy must be stopped before this begins High Risk patients 1.age 2 wounds 3. impaired circ, edema, infection, inflamm impd sensory: SCI Methods Heat moist: dry: Cold Dry Moist

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Heat Treatment 1. Indications a) muscle spasm b) inflammation Contractures

Contraindications -1st 24 hours after trauma -active bleeding Cold Treatment Indications a) b) 2. Contraindications a) b)

c)

c)

Nursing Implications correct temp? assess pt before, during, and after apply for specified time facility protocol teach pt mot to adjust temp

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