Surgical Asepsis/ wound care

Achieving surgical asepsis steps

apply hair covering, mask, protective eye wear, and shoe covers, performing hand scrub (w/ surgical hand scrub and clean subungal part around cuticles), applying sterile gown and gloves,

Antimicrobial agent

removes debris and transient micro organisms

Visual assessment

location, shape, size, colors, exudate, bleeding, any tissue that impairs healing (necrosis, erythematous or infected tissue, tunneling, undermining, edema), tissues that helps healing, (granulating tissue, clean wound edges), temp changes from very warm (w/ infection) to very cold (vascular compromise)

Pressure injury

area of compromised skin integrity over bony prominence that results from prolonged pressure

Shear

friction, results in stretching and breakage of blood vessels in area, leading to soft tissue ischemia, can be reduced by keeping head lower than 30 degrees

Stage 1

nonblanchable redness caused by pressure typically over bony prominence

Stage 2

full thickness tissue loss without exposed muscle or bone and the possibility of undermining or tunneling

Stage 4

full thickness tissue loss with exposed bone or muscle. Possibility of undermining or tinning and sometimes eschar or slough

Eschar

black scab like material

Clough

white yellow dead tissue

Braden

used to assess pressure injury risk, sensory perception, moisture, activity, mobility, nutrition, and friction/shear

Phases of heal thing

inflammatory, proliferative phase, maturation,

Inflammation phase

begins once skin is injured and continues for 24 hours in partial thickness healing. Color changes, heat, swelling, pain, loss of function. WBC present are primarily neutrophils, lymphocytes, and macrophages

Proliferative phase

wound healing restores skin integrity by filling in the wound with new tissue. angiogensis, granulation tissue resulted from capillary system

Angiogenesis

new blood vessels form within the wound

Granulation tissue

bright red tissue that manifestation of wound healing but is prone to bleeding with any trauma

Maturation phase

completes the wound healing process may take more than 1 year. Begins and overlaps with proliferation phase

Intrinsic factors that affect wound healing

age, chronic illness, skin

Extrinsic factors that affect wound healing

meds, cancer treatments , nutrition, stress, length of time required for wound to heal

Chronic wounds

prolonged time of healing,

Three types of dressing

maintain moisture, absorb moisture, add moisture

Dry dressing

gauze pad, wounds with small amounts of exudate (will stick if heavy exudate), pour 0.9% sodium chloride over area to moisten dressing for easier removal. Sterile clean environment. Non adherent gauze like petrolatum gauze can eliminate dry dressing from adhering

Wet to dry dressing

have been used extensively for wounds requiring debridement, no longer considered good practice because painful when removed, nonselective w/ debridement as they take healthy and necrotic tissue when removed, time consuming to apply and frequency of dressing changes, cause maceration of surround wound edges b/c moisture, cross contamination saturated gauze does not provide any barrier to environment

Sophisticated dressings or wound VACs

instead of wet dry dressings

Chemical impregnated dressing

speed up healing process, used when agents in dressing are likely to respond to wound, povidone iodine, silver, petroleum, collagen, and antibiotics. Some require secondary dressings

Foam dressings

absorbent, moisture healing environment while protecting wounds, beneficial when used over bony prominence to provide additional protection, self adherent or non adherent (required means to securement)

Alginate dressing

seaweed, provides mist environment for healing and absorption of exudate, establish hemostasis, do not adhere to wounds with large amounts of exudate . Packing deeper wounds. Should not be used in dry wounds

Hydrogel dressing

costly, absorbent properties, no affect on hemostasis, composed of polymer gel (can absorb exudate vertically), sheets that swell, cut dressing to size a little larger that wound

Would fillers

manufactured as pastes, powders, gels, and beads for providing moisture healing environment. Helps soften underlying necrotic tissue to speed up debridement. Deep wounds with exudate less useful with dry wounds

Transparent film dressing

thin layer of plastic that covers wound, no absorption but creates barrier to environment, allows some oxygen exchange and moist environment to promotes healing and autolytic debridement. Wounds with necrotic tissue or superficial skin tears.

Hydrocolloid dressing

autolytic debridement, some absorption, moist wound healing enviro. Not recommended for infected wounds but for wounds vulnerable to infection. DO NOT USE ON GANGRENE OR ISCHEMIC wounds

Wound closure

sutures, staples, tissue adhesive

Topical wound agent

antiseptic, antibacterial, anti fungal, chemical debridement gels/ ointments, barrier creams, skin cleansers

Wound cleansing

0.9% sodium chloride solution to help get rid of wound area necrotic tissue, purulent drainage, debris.

Cleansing methods

passive, mechanical, pressurized irrigation

Passive irrigation

solution and gravity, top to bottom cleansing

Mechanical cleaning

use of gauze and cleansing solution to clean contaminated wound areas

Debridement

removal of nonviable tissue

Negative pressure wound therapy (NPWT) or vacuum assisted closure (VAC)

assist in wound contraction and provide debridement and removal of exudate, suction to wound area, removed drainage, reduces bacterial counts, promotes granulation.

Open drainage systems

absorbent dressing applied to area to collect drainage, protect surrounding skins, prevent wound contamination. Diff. Assessing amount go drainage, controlling transmission or micro organism, small plastic tube that collapses easily.

Closed drainage

use compression and suction to remove drainage and collect it in reservoir, reduce risk of infection, accurate measurement for drainage

Support surfaces for the prevention or treatment of skin breakdown

non powered support surface, low air loss mattress, air fluidized bed surface, lateral rotation