Skills Exam 3

Patient Assessment and Wound Types

• Pus
    - Color: Yellow, white
    - Indicates infection.

• Sanguineous
    - Color: Red

• Serous
    - Color: Pink

• Serosanguineous
    - Color: Pinkish red

• Stomas
    - Should be:
      - Moist
      - Not burn
      - Should be well secured with drainage pouch to protect surrounding skin.

Stoma Care

• When cutting around a stoma wafer:
    - Avoid too much space around the wafer to prevent dry skin from being exposed.

Stages of Healing

1. Homeostasis

2. Inflammation
     - Duration: 3 to 5 days
     - Signs: Redness, warmth, throbbing.

3. Proliferation Phase
     - Duration: Approximately 3 to 4, up to 5 days until 2 to 4 weeks
     - Key Processes:
       - Production of granulation tissue
       - Epithelialization.

4. Remodeling or Maturation Phase
     - Key Process: Formation of scarring.

Wound Management in Case of Complications

• Evisceration:
    - Use saline-soaked gauze to cover the exposed area and call for assistance immediately.
  

Aseptic Techniques

• Medical Aseptic: Clean technique

• Surgical Aseptic: Sterile technique

• True/False Statements:
    - Sterile field must remain sterile: True
    - It is acceptable to turn your back to a sterile field: False
    - Contact with unsterile objects contaminates: True
    - Sterile objects can become unsterile if left out too long: True.

Pressure Ulcer Stages

1. Stage I:
     - Non-blanchable erythema of intact skin.

2. Stage II:
     - Partial thickness skin loss involving the epidermis and/or dermis. May present as a blister or shallow crater.

3. Stage III:
     - Full thickness skin loss with visible subcutaneous fat but no visible muscle, bone, or tendon.
     - Connective tissue visible (fatty tissue).

4. Stage IV:
     - Full thickness skin loss with exposed muscle, bone, or tendons.

5. Unstageable:
     - Full thickness tissue loss where the base is covered by slough or eschar.

Wound Drainage Evaluation

• Preferred drainage: Serosanguineous (indicates healing without infection).

Infection Control

• CAUTI:
    - Stands for Catheter-Associated Urinary Tract Infection
    - Can occur from hospital-acquired infections related to catheter insertion.

Urinary Catheter Management

• French Sizes:
    - 14-16 French: Ideal for adults
    - 8-10 French: Suitable for older children (10-12 years).

• Removing a Catheter:
    - Use clean gloves, no need for sterile technique.
    - Always check the balloon size before removal; standard balloon may be 10 cc, but some can be as large as 30 cc.

• Washing after removal: Ensure to clean the area effectively, starting from the center outwards (clean to dirty).

Wound Assessment

• Color codes:
    - Red: Healthy, granulation tissue
    - Yellow: Slough tissue that needs removal for granulation to form
    - Black: Necrotic tissue, requires surgical debridement and is classified as unstageable if not assessable.

Procedures for Using Sterile Gloves

• How to don and doff sterile gloves:
    - Remember that the area around the edge is not sterile.
    - If contamination occurs, change gloves and start again.

Administration of Enemas

• Position: Left side is preferable for administering enemas.

• Retention: Hold position for at least 5 minutes.

Tracheostomy Suctioning Techniques

• Prepare all necessary equipment in advance.

• Patient should be informed and comfortable.

• Total number of suction passes: 3.

• Ensure patient has humidified oxygen on while suctioning.
    - Use non-dominant hand for suctioning, which becomes non-sterile.

• Suctioning time should not exceed 15 seconds to avoid distress.

• After suctioning, immediately re-administer oxygen as needed to ensure patient safety.