Term
| medical asepsis/clean technique |
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Definition
procedures that decrease the # of pathogens
used to prevent HAIs |
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Term
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Definition
a form of medical asepsis, destroys microorganisms, but not spores
often used: lysol, virex, alcohol (most common)
used to prevent HAIs |
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Term
| surgical asepsis/sterile technique |
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Definition
practice used to render and keep objects and areas FREE of microorganisms and spores
used to prevent HAIs |
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Term
| when is surgical asepsis used |
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Definition
-wound care
-IV insertion
-FC insertion
-upkeep of access lines
-injections
-trach care
-repiratory suctioning |
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Term
| 4 methods of physical sterilization/disinfection |
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Definition
1) steam (autoclaving)
2) boiling water (boil for 10 mins)
3) dry heat (used for metal-heat oven to 350* for 2 or more hours)
4) radiation (used for heat sensitive items) |
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Term
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Definition
-outer bottle and cap are unsterile
-check expiration date, initial/date/time when opening a new bottle (entire bottle must be used in 24 hours)
-if already open, waste a little
-label should face palm
-fluid should not touch side of bottle |
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Term
| to add an item to your sterile field |
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Definition
| open package away from sterile field and drop item into the sterile field from 6 inches above |
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Term
| setting up a sterile field |
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Definition
-wash hands
-outer 1 inch of packages are considered unsterile
-do not cough/sneeze/reach arms over sterile field
-keep sterile items covered until absolutely ready to use |
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Term
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Definition
-hand washing
-gloves, gowns, goggles, masks
-do not recap needles-use sharps container
-use mouthpiece barrier during CPR
-body fluids are considered contaminated on all pts
-red bags for soiled trash
-double bag soiled linen
-transport lab specimens in a sealed container |
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Term
| accidental exposure to body fluids |
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Definition
-report to charge nurse
-wash immediately with warm soapy water
-incident report
-report to infection control nurse
-consent for pt testing
-nurse is tested at 3 mos, 6 months, 1 year
-counseling |
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Term
| infectious disorders resistant to treatment |
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Definition
have mutated from overexposure/undertreatment of antibiotics
MRSA
VISA
VRE |
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Term
| most often weight gain/loss is r/t... |
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Definition
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Term
| height and weight measures... |
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Definition
overall health
hydration
nutrition |
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Term
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Definition
adults: standing scale, unless pt cannot stand (chair scale)
children <2 years old: measured in recumbent position
infants weighed naked, children weighed in only underwear |
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Term
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Definition
1) untie middle of gown IF it was tied in front
2) grab outside of one glove with opposite hand and peel off, turning glove inside out; ball the glove up in your gloved hand
3) slide fingers of ungloved hand under remaining glove (do not touch outside of glove) and peel off glove over the top of the balled up glove
4) remove goggles/face shield by touching headband/ear pieces; lift away from face
5) undo ties of gown around neck and waistline; allow gown to fall off of shoulders; turn gown inside out and roll into a ball
6) undo neck ties or elastic part of mask; do not touch front of mask
7) wash hands immediately |
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Term
| body's first line of defense |
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Definition
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Term
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Definition
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Term
| intentional wound vs unintentional wound |
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Definition
INTENTIONAL: incisions, injections, blood draws; clean; controlled bleed; low risk of infection
UNINTENTIONAL: unexpected trauma, burns; uneven; uncontrolled bleed; higher risk of infection |
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Term
| opened wound vs closed wound |
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Definition
OPEN: broken skin; higher risk of infection; could be intentional or unintentional
CLOSED: soft tissue damage; no broken skin; (bruise, stage 1 ulcer) |
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Term
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Definition
deep
partial or full thickness |
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Term
| clean wound vs contaminated wound |
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Definition
CLEAN: no sign of infection or contamination
CONTAMINATED: infected or contains debris |
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Term
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Definition
a foreign object enters skin
foreign object might shatter |
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Term
| avulsion wound vs abrasion wound |
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Definition
AVULSION: tear; might damage veins/nerves/muscle; (sheering)
ABRASION: superficial injury; (rug burn) |
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Term
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Definition
| object is impaled into skin |
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Term
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Definition
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Term
| incision wound vs laceration wound |
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Definition
INCISION: surgical cut
LACERATION: accidental traumatic skin opening |
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Term
| microbial wound vs chemical wound |
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Definition
MICROBIAL: with microbes
CHEMICAL: from chemical agents; (acid, bleach) |
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Term
| thermal wound vs irradiation wound |
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Definition
THERMAL: from heat or cold
IRRADIATION: from radiation |
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Term
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Definition
| healing through increased blood supply, WBCs, antibodies, and waste removal |
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Term
| nutrition needed for wound healing |
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Definition
PROTEIN needed to develop antibodies and blood cells
VITAMINS A,B,C,E for healing
VITAMIN K for clotting
ZINC, COPPER, IRON for healing |
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Term
| why do proximal extremities heal faster than distal extremities |
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Definition
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Term
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Definition
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Term
| 4 phases of wound healing |
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Definition
1) homeostasis
2) inflammatory
3) proliferation/fibroplasia
4) remodeling/maturation |
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Term
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Definition
-begins immediately
-body seals off wound with clotting
-phagocytosis
-swelling, pain, warmth, exudate |
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Term
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Definition
-lasts 3-4 days
-mild temp, increased WBC, dark pink, swelling
-fibroblasts fill in wound |
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Term
| proliferation/fibroplasia phase |
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Definition
-lasts 4-21 days
-granulation tissue forms
-no syptoms
-bleeds easily |
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Term
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Definition
highly vascularized tissue
healing tissue
pink |
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Term
| remodeling/maturation phase |
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Definition
-begins weeks later
-scar is formed (avascular) |
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Term
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Definition
| doesn't sweat, grow hair, tan |
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Term
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Definition
primary intention: wound is clean, straight; edges are well approximated; minimal scarring
secondary intention: large wounds; not approximated; heals with granulation tissue; larger scar; longer time healing
tertiary intention: wounds sutured; large scar; higher chance of infection |
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Term
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Definition
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Term
| dessication vs maceration |
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Definition
DESSICATION: dehydrated skin; lack of fluid
MACERATION: wet skin |
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Term
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Definition
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Term
| dehiscence vs evisceration |
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Definition
DEHISCENCE: wound reopens
EVISCERATION: internal organs/tissue protrudes through open wound |
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Term
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Definition
abnormal passage from one organ to another
poor wound healing |
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Term
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Definition
serous: clear, watery
sanguinous: bloody
purulent: made of WBCs, bacteria, debris; foul odor; pus |
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Term
| most common cleaning agent |
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Definition
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Term
| length of time for tube feedings |
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Definition
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Term
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Definition
gastrostomy tube
placed under general anesthesia |
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Term
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Definition
| can be placed at bedside with local anesthetic |
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Term
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Definition
low profile gastrostromy device
often called a button
useful for children
no external tubing
can submerge in water
concealed easily |
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Term
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Definition
tube goes from nose to stomach
aspiration is a major risk
bowel perforation possible |
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Term
| confirmation of tube placement |
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Definition
chest xray
aspirating to check for gastric contents (pH should be acidic: intestines 7 or higher; stomach 5.5 or less) |
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Term
| administering medications into tubes |
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Definition
-give meds one at a time
-give 50 cc water before meds and 50 cc water after
-pills crushed and mixed with water, do not mix with formula |
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Term
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Definition
-check every 4-6 hours
during feeding times
-any residual >100 cc, feeding is stopped and dr is called
-always replace residual
-pt sits in semi-fowler's position |
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Term
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Definition
| always intermittent and low |
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Term
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Definition
clear tube with a small amount of air
gentle, constant pulling
oral hygiene immediately afterwards |
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Term
| first step of placing or removing a tube |
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Definition
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Term
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Definition
intact skin
nonblanchable redness |
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Term
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Definition
partial thickness loss of dermis
red/pink wound bed, no slough
similar to a ruptured blister |
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Term
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Definition
full thickness tissue loss
fat might be visible, but not bone/tendon/muscle
may be slough, undermining, tunneling |
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Term
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Definition
full thickness tissue loss with exposed bone, tendon, muscle
slough/eschar present
tunneling, undermining |
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Term
| unstageable pressure ulcer |
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Definition
full thickness tissue loss
covered by slough/eschar
cannot be staged until slough/eschar is removed
(stable eschar on the heels-dry, intact-should be left alone) |
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Term
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Definition
identifies whether pt is at risk for pressure ulcers
the HIGHER the number, the LOWER the risk
examines mental status, continence, mobility, activity, nutrition |
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