List the principles of surgical asepsis and explain the rationale for each principle. -
ANSWER -sterile object remains sterile only when touched by another sterile object
-place only sterile objects on sterile field
-sterile object or field out of range of vision or an object held below a person's waist is
contaminated
-sterile object becomes contaminated by prolonged exposure to air
-a sterile object or field becomes contaminated by capillary action when a sterile surface
comes in contact w/ a wet contaminated surface
-b/c fluid flows in direction of gravity, sterile object becomes contaminated if gravity causes
a contaminated liquid to flow over surface of an object (keep wet hands up above elbows,
dry from fingers to elbows)
-the edges of a sterile field or container are contaminated (1-inch border)
risk factors for pressure ulcer development and nursing interventions to reduce ulcer
development - ANSWER SHEAR-keep HOB <30 degree angle. reposition frequency is
determined by tissue tolerance, lvl of activity, and mobility. std=every 1-2 hrs for bed bound,
every 1 hr for chair. use support surfaces to redistribute wt
1
,FRICTION-minimal layers of bed linens between pt and the surface. keep heels off bed. teach
pt's to reposition wt every 15 min. use assisitive devices when transferring or turning pt.
MOISTURE-use an incontinence cleanser and moisture barrier cream, toileting schedule,
fecal incontinence collector or condom cath, use underpads or diapers that wick moisture
AWAY from skin rather than trap it
NUTRITION-nutrition assessment, ensure adequate intake of PROTEIN, fat, and carbs,
consult RD, ensure adequate fluid intake
INFECTION-
AGE-thin skin increases
Partial-thickness wound - ANSWER wounds that heal by primary intention and shallow
wounds that only involve loss of epidermis/dermis
heal by resurfacing of wound with new epidermal cells
Partial-thickness wound repair - ANSWER Inflammatory response-[erythema/edema
inc WBC to site]. usually subsides in <24 hrs
Epidermal repair-[epidermal cells migrate across wound]. moist env-heal in ~4days, dry env-
heal in 7 days
Dermal repair-[epidermis thickens and anchors to cells]. resumes normal fxn. pink, dry, and
fragile skin. occurs concurrently w/ epidermal repair
Full-thickness wound - ANSWER involve tissue loss and extend to at least
Sub Q layer. can be acute (surgical wound) or chronic (pressure ulcer)
2
, can be healed by primary or secondary intention
Full-thickness wound repair - ANSWER Hemostasis-[controls bleeding]. platelets cause
coag and vasocontriction, and break down and release growth factors (GF initiate entire
wound healing process). DOES NOT occur in wounds healing by secondary intention!
(comprimises repair process)
Inflammation-[establish clean wound bed & bacterial balance]. brings WBC to area, cleans
site, releases addt'l GF. lasts 3 days in acute wounds, >3 days in chronic wound (pressure
ulcer)
Proliferation-[prod. of new tissue, epithelialization, contraction]. w/ primary intention new
capillary networks form to provide O2 and nutrients and synthesis of collagen. wound
contracts as collagen fibers increase in size. epithelial cells migrate and cover defect (occurs
faster in moist env!!!!). w/ pressure ulcer, takes longer. as granulation tissue fills defect,
contraction and epithelialization can occur. contraction is more important in secondary
wounds b/c it reduces amnt of granulation tissue needed to fill defect!!!
Remodeling-[reorganizes collagen to produce more elastic, stronger collagen for scar tissue].
lasts up to 1 year. tensile strength never more than 80% or non-damaged tissue. remodeling
phase is same for primary and secondary intention wounds
Demonstrate correct examination of wounds and
wound drainage - ANSWER ASSESSMENT
-anatomical location
-extent of tissue involvement
-size
-tissue type
-% of wound tissue
-volume and color of wound exudate
3
ANSWER -sterile object remains sterile only when touched by another sterile object
-place only sterile objects on sterile field
-sterile object or field out of range of vision or an object held below a person's waist is
contaminated
-sterile object becomes contaminated by prolonged exposure to air
-a sterile object or field becomes contaminated by capillary action when a sterile surface
comes in contact w/ a wet contaminated surface
-b/c fluid flows in direction of gravity, sterile object becomes contaminated if gravity causes
a contaminated liquid to flow over surface of an object (keep wet hands up above elbows,
dry from fingers to elbows)
-the edges of a sterile field or container are contaminated (1-inch border)
risk factors for pressure ulcer development and nursing interventions to reduce ulcer
development - ANSWER SHEAR-keep HOB <30 degree angle. reposition frequency is
determined by tissue tolerance, lvl of activity, and mobility. std=every 1-2 hrs for bed bound,
every 1 hr for chair. use support surfaces to redistribute wt
1
,FRICTION-minimal layers of bed linens between pt and the surface. keep heels off bed. teach
pt's to reposition wt every 15 min. use assisitive devices when transferring or turning pt.
MOISTURE-use an incontinence cleanser and moisture barrier cream, toileting schedule,
fecal incontinence collector or condom cath, use underpads or diapers that wick moisture
AWAY from skin rather than trap it
NUTRITION-nutrition assessment, ensure adequate intake of PROTEIN, fat, and carbs,
consult RD, ensure adequate fluid intake
INFECTION-
AGE-thin skin increases
Partial-thickness wound - ANSWER wounds that heal by primary intention and shallow
wounds that only involve loss of epidermis/dermis
heal by resurfacing of wound with new epidermal cells
Partial-thickness wound repair - ANSWER Inflammatory response-[erythema/edema
inc WBC to site]. usually subsides in <24 hrs
Epidermal repair-[epidermal cells migrate across wound]. moist env-heal in ~4days, dry env-
heal in 7 days
Dermal repair-[epidermis thickens and anchors to cells]. resumes normal fxn. pink, dry, and
fragile skin. occurs concurrently w/ epidermal repair
Full-thickness wound - ANSWER involve tissue loss and extend to at least
Sub Q layer. can be acute (surgical wound) or chronic (pressure ulcer)
2
, can be healed by primary or secondary intention
Full-thickness wound repair - ANSWER Hemostasis-[controls bleeding]. platelets cause
coag and vasocontriction, and break down and release growth factors (GF initiate entire
wound healing process). DOES NOT occur in wounds healing by secondary intention!
(comprimises repair process)
Inflammation-[establish clean wound bed & bacterial balance]. brings WBC to area, cleans
site, releases addt'l GF. lasts 3 days in acute wounds, >3 days in chronic wound (pressure
ulcer)
Proliferation-[prod. of new tissue, epithelialization, contraction]. w/ primary intention new
capillary networks form to provide O2 and nutrients and synthesis of collagen. wound
contracts as collagen fibers increase in size. epithelial cells migrate and cover defect (occurs
faster in moist env!!!!). w/ pressure ulcer, takes longer. as granulation tissue fills defect,
contraction and epithelialization can occur. contraction is more important in secondary
wounds b/c it reduces amnt of granulation tissue needed to fill defect!!!
Remodeling-[reorganizes collagen to produce more elastic, stronger collagen for scar tissue].
lasts up to 1 year. tensile strength never more than 80% or non-damaged tissue. remodeling
phase is same for primary and secondary intention wounds
Demonstrate correct examination of wounds and
wound drainage - ANSWER ASSESSMENT
-anatomical location
-extent of tissue involvement
-size
-tissue type
-% of wound tissue
-volume and color of wound exudate
3
