Funds Ch. 22 Funds Ch. 22

Question Answer
the method used to prevent contamination during invasive procedures, or procedures that involve entering body cavities surgical asepsis or sterile technique
method that delivers steam under pressure, with heat ranging from 250-270 degrees F to sterilize instruments that will not be harmed by heat and water under pressure autoclaving
boiling method of boiling instruments and supplies in water for 10 minutes kills non-spore forming organisms
this method kills pathogens on sutures, some plastics, and biological materials that can't be boiled or autoclaved ionizing radiation
This method is used to kill pathogens on equipment and supplies that cannot be heated chemical disinfectant
gaseous disinfection this method kills pathogens on supplies and equipment that are heat sensitive or must remain dry
List the types of sterilization autoclaving, boiling, ionizing radiation, chemical disinfection, gaseous disinfection
How many inches of the border of a sterile packaged item is considered contaminated? 1 inch
How do you check the sterility of an item? expiration date, check for black hash marks on the indicator tape, examine the packaging for evidence that it has been wet (strike-through) or for holes or tears
Sterile Conscious the awareness of potential or certain contamination of a sterile field or item- it is up to the nurse to be responsible
When would you use sterile technique? entering body cavities, veins, or arteries; when caring for patients with non-intact skin; when handling needles, syringes, and lancets
a closed, discolored wound cause by blunt trauma, better known as a bruise contusion
a superficial open wound; includes scrapes, scratches, rub-type wounds such as carpet burn or a scraped knee abrasion
an open wound that results when a sharp item pierces the skin puncture wound
an open wound that results when a sharp item pierces the skin and remains embedded in the tissue penetrating wound
an open wound made by the accidental tearing or cutting of tissue, usually caused by knives, pieces of glass, or metal pieces lacerations
a wound resulting from pressure and friction, skin may be intact and erythemic or may be broken pressure ulcer
clean wound a wound that is not infected
clean-contaminated wound a wound that was surgically made, is not infected, but has direct contact with the normal flora in either the respiratory, urinary, or GI tract-has potential to become infected
contaminated wound this can be a surgical wound or a wound caused by trauma that has been grossly contaminated by breaking asepsis
Infected wound a wound in which the infectious process is already establish, as evidenced by high # of microbes and either purulent drainage or necrotic tissue
purulent containing puss
necrotic dead
Classic signs of infection erythema, increased warmth, edema, pain, odor, drainage
a wound that has a high number of microbes present but is without signs of infection Colonized
reduced blood flow to an area ischemia
List the most common places to develop a pressure ulcer sacrum, buttocks, greater trochanters, elbows, heels, ankles, occiput (back of head) and scapulae
Six-classifications of a pressure ulcer Deep Tissue InjuryStage 1Stage 2Stage 3Stage 4Unstageable
Stage 1 pressure ulcer characteristics Indicated by erythema that remains for at least 15-30 minutes and will not blanch; may feel warm and firm
Stage 2 pressure ulcer characteristics partial-thickness loss of dermis, blisters and broken blisters, erythema surrounding the skin break, harder to heal and may allow microbes to enter and multiply so infection is possible
Stage 3 pressure ulcer characteristics full-thickness loss involving damage to epidermis, dermis, and subq tissue; does not involve muscle or bone; may be tunneling or undermining; tend to be infected, may have drainage
Stage 4 pressure ulcer characteristics deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone; may be tunneling and undermining; may be extremely slow to heal
Unstageable pressure ulcer characteristics involve full-thickness tissue loss but are impossible to accurately stage due to eschar; eschar should not be removed because it is covering and protecting the damaged tissue underneath it
ulcer that develops when venous blood flow is sluggish, generally in the lower extremities, allowing deoxygenated blood to pool in the veins stasis ulcer
a channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin sinus tract
scale for predicting pressure sore risk Braden
keloid raised scar
type of wound closure where the edges are approximated and the wound is sutured closed first intention
type of wound closure where the edges are irregular and can't be brought together, wound must be left open to gradually heal second intention
type of wound closure where the wound is left open for a time to allow granulation tissue to form, then it is sutured closed third intention
Factors that influence wound healing age, lifestyle, additional illness and wounds, nutritional status, oxygenation, medications, and tension on edges of the wound
dehiscence a partial or complete separation of the outer layer of a wound
evisceration when a wound opens an abdominal contents may spill out
bleeding profusely hemorrage
drainage that looks like blood sanguineous
drainage that is pink, blood and serum serosanguineous
drainage that is clearer and slightly yellow fluid serous
Penrose drain open drain in which multiple dressings are needed to soak up drainage
Jackson-Pratt looks like a grenade, make sure it is compressed, closed drain
Hemovac round, closed drain, make sure it is compressed
dressing used on stage 1 tegaderm
dressing used on stage 2 tegaderm or hydrocolloid
dressing used on stage 3 hydrocolloid or duoderm if not infected-if infected, wet to dry and use saline
dressing used on stage 4 4×4's, ABD , wet to dry
What are the 4 things you need to remember to chart about the drainage? TypeAmountColorOdor
Name 4 other things besides TACO that you should mention in your wound charting location, open/closed, dressings used, measure the size, condition of skin around wound
In which direction do you clean a wound? inwards to outwards
Hard, dry, leathery dead tissue Eschar
New tissue that grows and fills in a wound Granulation tissue
Elderly, malnourished, incontinent, immobile, having impaired circulation Risk factors for pressure ulcer development
3 phases of would healing InflammatoryReconstruction (proliferation)Maturation (remodeling)
Occurs when a wound begins to heal, roughly 21 days after injury Reconstruction (proliferation)
Occurs when the wound contracts and the scar strengthens Maturation (remodeling)

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