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INTRO TO STERILE FIELDS

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INTRO TO STERILE FIELDS

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Medical Asepsis

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Practices that reduce the # of micro-organisms

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Things considered "clean"

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clean utility room, clean gloves, freshly washed hands, things above your waist, fresh linen

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Things considered "dirty"

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dirty utility room, gloves after use, hands after patient contact, anything below your waist or behind your back (b/c of gravity and b/c of being out of the line of sight)

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Surgical Asepsis (sterile technique)

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Practices that eliminate all micro-organisms -use in: any procedure that is causing a break in skin or is entering a sterile part of body AND for care for high risk groups -never assume that object is sterile: check that it is labeled sterile, packaging is intact + it has an expiration date

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Principles of Wound Care

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-Moisture facilitates growth of micro-organisms and facilitates easier travel of micro-organisms so dressings should be changed more frequently if wound is draining a lot -Dressings should NOT be wet but wound bed should be moist

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WOCN

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Wound Ostomy Care Nursing - trained in assessing which equipment is appropriate for wound

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Principles of Surgical Asepsis

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-Sterile objects become non sterile when touched by non sterile objects -1 inch border of sterile field is considered non sterile -Always face sterile field -Sterile objects that are out of line of vision are considered non-sterile -Sterile equipment or areas must be kept above the waist -Fluid flows in direction of gravity so hold instruments with the tip facing down -Sterile objects can be come non sterile by prolonged exposure to airborne micro-organisms

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Setting up Sterile Field

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1) Clean work surface prior to beginning (usually bedside table) + raise height of work surface and patient bed so it is above waist level 2) Create triangle between sterile field, patient + garbage -> sterile - clean - dirty 3) Open sterile dressing: top flap, side flap, grab sterile forceps and open last (bottom) flap 4) Keep the handles of forceps within 1 inch non sterile border but keep tips in the sterile field 5) Adding sterile objects to field --> either drop onto field or use forceps

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Common Types of Dressing Material

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-2x2's + 4x4's: used for cleaning + drying wound -Abdominal dressings: great for moderate to copious amounts of drainage -Tegaderm Hydrocolloid: Outer layer is waterproof and inner layer is gel coating that absorbs exudate --> commonly used on pressure ulcers on coccyx -Transpore tape: most commonly used, clear + waterproof Micropore tape: hypoallergenic paper tape, gentle on skin Medipore tape: fabric tape, perforated for easy tearing and length choice Skin prep: liquid dressing that forms a protective film over skin, protects skin from tape allergies, reduces risk of skin damage during removal of tape, improves tape adhesion

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Purpose of Dressing Wounds

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-Protect from mechanical injury -Prevent wound infection -Provide / maintain the humidity of the wound -Absorb drainage -Splint or immobilize wound site to enable healing + prevent injury -Provide psychological / aesthetic comfort

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PRESSURE ULCERS

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PRESSURE ULCERS

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Pressure Ulcers

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-Any lesion caused by unrelieved pressure that results in damage to underlying tissue -Usually occur over bony prominences -1 in 4 patients -2 other major factors are: Friction (force acting parallel to skin surface, ex. sheet rubbing against skin), and Shearing force (combo of pressure + friction, occurs commonly to pts in fowlers position as they slide downwards)

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Risk Factors

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-immobility (turn Q2-3h) -Inadequate nutrition -Poor circulation -Certain health challenges -Fecal + urinary incontinence -Decreased LOC --> unable to recognize + respond to prolonged pressure pain -Diminished sensation + neuropathy -Age -Other --> poor lifting techniques, incorrect positioning, hard surfaces, incorrect application of pressure relieving devices

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Stage 1 Ulcer

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-Non blanchable erythema (remains red when pressed) -Intact skin (still just @ top level - epidermis)

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Stage 2 Ulcer

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-Damage to epidermis extending into dermis (no deeper) -Ulcer is superficial, looks like an abrasion, blister, shallow crater

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Stage 3 Ulcer

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-Damage to full thickness of skin, extending into but not through the subcut layer -Damage or necrosis of subcut tissue -May or may not have undermining

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Stage 4 Ulcer

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-Damage to full thickness of skin + subcut tissue -Damage extends into muscle, bone, tendons -Undermining + sinus tracts may be present

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Braden Scale

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-Tool that helps HCPs identify a pts risk for developing pressure ulcers -6 categories assessed: sensory, perception, moisture, activity, mobility, nutrition, friction + shear -Lowest score: 6, Highest Score: 23 -Pt w/ score less than 18 is considered high risk

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Student responsibility for pts at risk

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-Turn clt Q2h -Assess skin Q shift -Encourage proper hydration + nutrition -Ensure proper transfer techniques are being used -Check clts pad regularly to assess need for changes -Apply barrier cream as needed

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SIMPLE WOUND CARE

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SIMPLE WOUND CARE

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Types of Wounds

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-Surgical incision -Abrasion: surface scrape -Puncture: penetration of skin + underlying tissue w/ sharp object -Laceration: tissues are torn apart + have jagged edges -Ulcer: localized open sore or lesion

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Types of Wound Healing: Primary Intention Healing

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-Tissue surfaces have been approximated + there is minimal or no tissue loss -Characterized by minimal scar formation + granulation

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Types of Wound Healing: Secondary Intention Healing

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-Extensive wound w/ considerable tissue loss in which the edges cannot be approximated -Repair time is longer -Greater scarring + increased susceptibility for infection

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Phases of Healing: 1) Inflammatory Phase

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-Initial response, initiated immediately after injury -3-6 days -Blood coagulation occurs + WBCs are released to defend against contamination of wound

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Phases of Healing: 2) Proliferative Phase

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-New tissue is being created -Extends from day 3-21 -Capillaries grow across the wound -New skin cells develop (re-epithelialization)

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Phases of Healing: 3) Remodelling phase

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-Last phase of healing occurs when the wound is closed -Extends from day 21-1/2 years post injury -Scar loses its red appearance

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Complications of Wound Healing

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-Hemorrhage: persistent bleeding, hematoma -Infection -Dehiscence: partial or total rupture of a sutured wound -Evisceration: protrusion of abdominal viscera through incision

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Cleaning Wounds

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-Removes micro-organisms, slough, necrotic tissue + other contaminants

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Cleaning Circular Wounds

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-Pressure Ulcers, drains -Start @ centre of wound bed + work your way outwards in concentric circles --> 1 gauze for complete circle -For drain site, clean around drain site starting @ centre working outwards in concentric circle --> 1 gauze

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Cleaning Incision

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-Cleanse wound "top to bottom" + "clean to dirty" (least drainage to most drainage) -Clean wound from top (where there is least drainage) to bottom (where there is most) -Start @ incision line + work your way outwards -I gauze for each stroke

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Types of Drainage: Serous

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-Contains serum, the clear portion of blood -Looks watery -Can be clear or yellowish

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Types of Drainage: Purulent

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-Presence of pus; thicker consistency -Green or yellow

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Types of Drainage: Sanguineous

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-Contains large amounts of blood -Red in colour

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Types of Drainage: Serosanguineous

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-Clear + blood tinged drainage -Pink in colour

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Types of Drainage: Purosanguineous

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-Pus + blood -Red w/ yellow or green

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Simple Dressing Change: Pre-Assessment

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Patient: -location of wound -intactness + amount/type of drainage on old dressing -Loosen one end + look inside -Pain --> admin analgesic as ordered -Use of bathroom b4 dressing change Other: -Check previous nursing notes, wound flow sheet and/or WOCN notes for dressing supplies needed -Check Kardex to see if you need to obtain wound culture

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Simple Dressing Change: Equipment

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-Sterile dressing tray --> check packaging for contents, dryness, intactness, expiry date -Clean gloves -Sterile gauze -Tape -Scissors -Disposable measuring tape -Sterile normal saline (NS) - check label for expiry date, intactness, discolouration of fluid (cleansing fluids expire 24 hours after opened, make sure to time + date container when opening new bottle) -Garbage bag

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Simple Dressing Change: Important Steps

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-Pre assessment -Gather equipment -Clean + dry workspace -Create triangle between sterile field, patient + garbage (sterile - clean - dirty, facing patient)

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Simple Dressing Change: Procedure

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-Set up sterile field + supplies using aseptic technique -With label in palm of your hand, pour NS into compartment --> do not splash onto sterile field -Remove old dressing w/ gloves, fold in half + throw away old dressing + gloves --> *assess drainage -Hand Hygiene -Cleanse wound --> look at each gauze after cleansing stroke + assess amount/type of drainage -Dry wound using same principles of cleansing -Assess wound -Obtain wound culture if needed -Apply dressing over wound --> use forceps, make sure dressing doesn't move around on skin once placed over the wound -Document

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Wound Assessment: Circular

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-Type, stage, location, length, width, depth -Condition of surround skin --> reddened? macerated? indurated? -Appearance of wound base --> red, slow, necrosis -Drainage/exudate --> type, amount, colour, odour -Signs of infection

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Wound Assessment: Incision

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-Location, length, approximation -Suture or staples? How many? intact? -Condition of surrounding skin --> reddened? macerated? indurated? -Complications -Drainage/exudate --> type, amount, colour, odour

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Wound Assessment: Drains/Tubes

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-Type of drain or tube, location -Condition of surrounding skin --> reddened ? macerated? indurated? -Sutures? how many ? intact? -Drainage/exudate --> type, amount, colour, odour -Signs of infection

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Assessing Drainage

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-Absent: no drainage -Scant: less than 5% of dressing is saturated -Minimal: 5-25% of dressing is saturated -Moderate: 25-75% of dressing is saturated -Copious: over 75% of drainage is saturated

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Documentation

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-Nursing Notes: (D) pre-assessment + assessment findings (A) procedure + wound products used (R) how pt tolerated procedure -Wound flowsheet if applicable -Update kardex (date of next dressing change)

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Would Culture

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-Obtained if infection is suspected -Always obtained after wound has been cleaned -How to collect: 1) use appropriate sterile swab as supplied by the agency 2) Rotate swab in an area of lean tissue in the open wound --> apply pressure as you rotate swab to elicit tissue fluid 3) Place in labelled container + send to lab

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CLT teaching

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-Keep dry -Call for nurse if it is visibly soiled or coming off -S/S of infections -How to do dressing change at home if being discharged -Diet to promote healing -Other teachings based on underlying cause

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Special Considerations for Pressure Ulcers

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-Prevention is key -Venous vs arterial ulcer -Documentation of length, width, depth is very important to determine if nursing interventions are working or not

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Special Considerations for Incisions

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-Usually drainage expected to change from sanguineous --> serosanguineous --> serous -Expected drainage may differ depending on surgery -Sudden discharge of drainage can indicate dehiscence -if there is NO drainage after 24-48 hours, may be left open to air

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Special Considerations for Drains + Tubes

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-Remove dressings carefully so as not to dislodge surgical drain/tube -Special drainage gauze avail that has slit on side in order to slide around drain/tube

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SUTURES, STAPLES + STERI STRIPS

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SUTURES, STAPLES + STERI STRIPS

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Purpose of them

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Hold skin + tissue edges together in order to promote wound healing

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Staples

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-Wide stainless steel clips, resemble paper staples -Common sites: arms, legs, abdomen, back, scalp (large areas) -Wounds on face, neck, hands + feet should NOT be staples as nerves + tendons are close to skin surface in those areas

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Staples: Benefits + Disadvantages

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BENEFITS: -inserted quickly --> less surgical time + anaesthetic used -less infection risk --> inserted w/ one time use gun, less handling of tissue -Lower tissue reactivity --> metal rarely causes immune response DISADVANTAGES: -More costly than sutures -Can interfere w/ imaging -Removal can cause more discomfort than suture

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Sutures

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-Common areas: face, neck, hands, feet, internal areas, hard to reach areas (inside mouth) -Come in diff thickness -Used for plastic surgery (very fine) -Made of: silk, cotton, linen, steel, polyester, nylon, wire, catgut (sheep/goat + only type that will dissolve) -Either absorbable (internal body tissue) or non absorbable (epidermal layer)

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Sutures: Benefits + Disadvantages

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BENEFITS: -More cost effective -Can be used in difficult to reach areas -Can be used to hold together internal body tissues -Lower dehiscence rate (b/c sutures completely encircle wound + are tied off) DISADVANTAGES: -Greater infection risk as suture is passed through skin repeatedly -Greater tissue reactivity (erythema) -More time consuming -Less tensile strength

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Sutures: Common Methods

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Interrupted (single/individual) -More time consuming but more reliable --> chance of dehiscence is low Continuous (1-beginning to end) -Quicker but less reliable --> if knot comes undone the whole thing will undo

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Retention Sutures

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-Rubber bars -Prevent dehiscence/evisceration -Seen in abdomen, chest (areas where more pressure is exerted)

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Assessment

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-# of sutures/staples -Drainage -Signs of dehiscence / evisceration -Signs of infection -Condition of surrounding skin -It is normal for skin around sutures/staples to be edematous + reddened for first 2-3 days after surgery--> if redness/swelling/pain is increasing that is cause of concern

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Suture/Staple Removal

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-Usually within 7-14 days --> Dr. will right order once healed -Exception: face --> usually 5 days -Longer you leave them in, the worse the scarring is -Dr. orders are necessary to remove -Order may read "remove every other"

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Equipment needed for removal

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-Dressing Tray -NS solution -Staple remover (staples) -Sterile scissors (sutures) -Sterile forceps (sutures) -Steri-strips --> tape that goes over wound for added support

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Removing Staples

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Pre-Assessment -confirm Dr. order for removal -assess pain levels prior + offer analgesic if needed (then wait 30 mins for effect) -Assess site prior to removal to ensure wound appears to be well healed + free of infection Procedure: -Use aseptic technique to clean wound -Insert tip of staple remover under each staple -Slowly close end of staple remover together -Pull up to free staple from skin -Put steri-strip on as you go

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Removing Sutures

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Pre-assessment: -same as for staples Procedure: -Use aseptic technique to clean wound -Gently lift suture w/ sterile forceps -Cut suture as close to skin as possible using sterile scissors -Gently lift + remove suture -Assess healing as you go -->some may need to be left in if incision does not appear fully healed in some areas -Leave uncomfortable sutures for the end -Once all sutures are removed, apply steri-strips

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Steri-Strips

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-Paper strips --> thick + thin -Tape closure -Allow for additional support post staple + suture removal -Also used for wound edges in small incisions or lacerations (no sutures/staples) -Fall off in 7-10 days

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Documentation of Removal

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Data: Assessment findings Action: Procedure (cleaning of wound, how many removed, application of steri strips, clt teaching completed) Response: How clt tolerated the procedure

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