3Principles of Surgical Asepsis Touching one sterile item with another sterile itemTouching one sterile item with a non-sterile item yields it contaminatedPartially unwrapped sterile package is contaminatedIf a question arises about sterility it is contaminatedA commercially packaged sterile item is not considered sterile past its recommended expiration dateOnce a sterile item is opened it is only a matter of time before it becomes contaminated- set up immediately before usingA sterile wrapper, if it becomes wet, wicks microorganisms from its supporting surface, causing contamination
4Principles of Surgical Asepsis (cont.) Any opened sterile item or sterile area is considered contaminated if it is left unattended (in OR and Delivery, covered with a sterile field)Coughing, sneezing, or excessive talking over a sterile field causes contaminationReaching across an area that contains sterile equipment has a high potential for causing contamination and therefore is avoidedSterile items that are located or lowered below the waist are considered contaminatedAvoid use of one inch perimeter margin of a sterile field
5SterilizationPhysical & chemical techniques that destroy all microorganisms and spores
6Physical Sterilization Radiation- (generally combined with other means). Effective for TB. Home means includes sunlightBoiling (212F X 15 minutes)Free-flowing steam (212F heat vapors)Dry heat- Similar to baking in oven ( F X 3 hours)Steam under pressure-most dependable. Autoclave method. Temperature over 212F. Pressure allows for hotter temperature than boiling. Heat sensitive tapes may be used.
7Chemical Sterilization Peracetic Acid-quick and reliable for sterilizing heat sensitive instruments. 30 minutesEthylene Oxide Gas-destroys microorganisms in 3 hours. Must air following (5 days) to remove traces of gas (could cause chemical burns)
8Surgical Asepsis Includes: Creation of a sterile environment Use of sterile equipment/supplies/solutionsSterilization of reusable suppliesSurgical hand scrubSurgical attire if in ORSterile glovesSterile fieldUse of sterile technique
10Surgical Asepsis Donning sterile gloves-Skill Donning sterile gown (during surgery and delivery of infants). Apply mask and hair cover first, then gown and last gloves. Gown will be wrapped from central supply with inside facing towards you so you can grasp and put on without contaminating outside of gown which must remain sterile.
11Sterile Technique Used for . . . Operating room Dressings Insertion of Foley cathetersAssisting physicians with procedures
13Creating a Sterile Field A work area free of microorganismsFormed using the inner surface of a cloth or paper wrapper that holds sterile itemsThe field enlarges the area where sterile equipment or supplies are placedSet the field up immediately before planning to use
14Creating a Sterile Field Skill Inspect the work area to determine the cleanliness and orderliness of the surface on which you will workObtain suppliesCheck the package to assure it is sealed and that the date has not expiredExplain what you will do to the patient
15Perform handwashing or hand antisepsis Open the barrier/field and lift one inch from the edge straight up from the wrapper, keeping the long edge from touching the work stationKeep above waist levelTwo ways to open the sterile field:Long way or short way are both acceptable as long as contamination does not occur
16Without shaking, lie the sterile field onto the work station without touching the sterile side of the field (keep your hands on the underside of the field)
17Donning Sterile Gloves Select a package of sterile gloves of the appropriate sizeRemove unnecessary items from the overbed tablePerform handwashing or alcohol-rub antisepsisOpen the outer wrapper of the glovesCarefully open the inner package and expose the sterile glove with the cuff end closest to you
19Pick up one glove at the folded edge of the cuff using your thumb and fingers Insert your fingers while pulling and stretching the glove over your hand, taking care not to touch the outside of the glove to anything that is nonsterileUnfold the cuff so the glove extends above the wrist, but touch only the surface that will be in direct contact with the skin
20Insert the gloved hand beneath the sterile folded edge of the remaining glove Insert the fingers within the second glove while pulling and stretching it over the handMay use gloved hands to fix fingersTake care to avoid touching anything that is not sterileMaintain your gloved hands at or above waist level
22Disposal of Contaminated Gloves HandoutGrasp outside of one cuff with other gloved hand; avoid touching wrist.Pull glove off, turning it inside out and discard.See handout
23Nursing Implications: Nursing Diagnoses Risk for infectionRisk for Infection TransmissionIneffective ProtectionDelayed Surgical RecoveryDeficient Knowledge
24Lab Practice for Sterile Gloves (pair) Lab Practice for Opening a Sterile Field
25Dressings and Wound Management Combination of Chapter 20 –Principles of Surgical Asepsis and Chapter 34 – Wound CareAssigned readings-chapter 20 and chapter 34, volumes one and two
26Goal of Wound Management To reapproximate the tissue to restore its integrity
27Wound Management Dressings Drains Sutures and Staples Bandages and BindersIrrigations
28PURPOSES OF A DRESSINGKeep the wound clean (use sterile supplies and sterile technique)Absorbing drainage (various dressing materials)Controlling bleeding (pressure dressings, wraps)Protecting the wound from further injury (i.e. duoderm)Holding medication in placeMaintaining a moist environment (hydrocolloid dressings, saline dressings, Alldress system)
29TYPES OF DRESSINGSGauze dressings-highly absorbent to cover fresh wounds that are likely to bleed or exude drainage (woven cloth fibers). Allows air flow to wound. Can debride new granulation, may need to moisten with NS if adhered to prevent debridement.Transparent dressings-Allows the nurse to assess the wound; commonly used to cover peripheral and central IV insertion sitesHydrocolloid dressing-They keep wounds moist because they heal more quickly in a wet environment. Self adhesive. May stay on 1 week.
30Dressing Supplies for Typical Surgical Dressing 2 X 2 gauze4 X 4 gauze (come single packs and multipacks)FluffsDrain spongesABD pad (Combine dressing)Rolled gauze- Kerlix or KlingSome agency have commercially packaged dressing kits (expensive)Solution to clean the wound (need to lip the containers to remove contamination)Sterile field (barrier)Sterile glovesUnsterile gloves to remove the old dressingBag/receptacle for disposal of old dressing
32TYPES OF DRAINSPurpose of drain is to remove blood and cellular debrisOpen drains-flexible tubes that provide a pathway for drainage toward the dressing. Called penrose and often used for abdominal surgery or kidney surgery.Drainage occurs by passive gravity & by capillary action (movement of a liquid at the point of contact with a solid, which would be the gauze)Closed drains-Hemovac and Jackson Pratt to pull fluid by creating a vacuum or negative pressure. Hemovac often used for orthopedic surgery.T-tube often used for gallbladder surgery or biliary surgery.
33Closed drains pull fluid by creating a vacuum or negative pressure Closed drains pull fluid by creating a vacuum or negative pressure. Open the vent on the receptacle, squeeze the drainage collection chamber and then cap the vent.
34Cleaning Around Drains Circular motionStart closest to the drain and go outwardDrains are often located beside a surgical wound, rather than within the wound line.After cleaning around the drain, a pre-cut drain sponge is placed around the drain.Expect more drainage from the exit point of an open drain, more gauze needed at this spot.
35Types of DressingsDry Sterile Dressing (DSD)-clean wound and apply dry gauze, dressing materialNewer recommendations may include clean technique rather than sterile technique. Follow agency protocols. For lab pass offs, will do sterile technique with a penrose drain in place.Wet to dry dressing-cover wound only with wet dressing then top with a dry gauze dressing; now expect wet to moist dressings rather than wet to dryPacking-follow medical orders for type, length, width and if packing is medicated packing or gauze packing (can be used for tunneling-use Q-tips to pack or sterile forceps)
36Dressing Change Follow medical orders for time, frequency Often “initial” (original) dressing is done by physician
37Other Orders for Dressing Change Reinforce dressing- add to existing dressing
38Assessing Wound Drainage Amount and Color:Serous-clear, watery, thin, may be straw coloredSanguineous-bright red, active bleedingSerosanguineous-pale red, mixture of clear & red fluid, more watery than sanquinousPurulent-thick yellow, green, tan or brown
39Wound Complications Dehiscence-reopening of surgical wound Evisceration-spilling of abdominal contents-many factors; usually follows dehiscence, abscess formation (should evisceration occur, cover with normal saline gauze to keep moist)Infection/abscess-associated with bowel/appendix-wound expect to see open wound
40Techniques to Keep a Dressing in Place Tape (different types of tape, dependent on patient’s tolerance/allergiesMontgomery straps- often used if need frequent dressing changesNetting (comes in several different sizes)
44Documentation of Dressing Change Describe the drainage on old dressingAssess and describe the wound, measureClean the wound (and drain site if applicable)Apply dressing materialDocument your assessment data, actions and patient response (DAR)
46BANDAGES AND BINDERSBandage-Strip or roll of cloth wrapped around a body part (example: Ace bandage)Binder-Type of bandage generally applied to a particular body partBinders and bandages hold dressings in place when tape cannot be used or the dressing is largeSupporting the area around a wound or injury to reduce painLimiting movement in the wound area to promote healing
47Ace Bandages Wrap from distal to proximal direction Avoid gaps Equal tensionFree of wrinklesRemove twice a dayCheck CSM-color, sensation, movement
48Irrigations Purpose: Rinse out cellular debris Remove purulent drainageBathe tissue with medicationsKeep area moist
50Irrigations Kits Solution Padding Basin Dressing Supplies Date and time all containersSterile solutions expire 24 hours after openingIrrigations done with smaller needle rather than irrigation syringe in kit
51Lab Practice Personal Dressing Kits- keep all supplies Lab demonstration by instructorStep by StepSet up disposal bag for old dressingApply unsterile (clean) gloves and remove old dressing. (If dressing sticks, apply saline and remove with clean glove). Assess wound and drainage, discard dressing, remove and discard gloves.Perform hand hygieneSet up fieldApply items to field (only add one sterile glove, other will be put on from bedside)Lip solution (i.e. normal saline) to clean the woundApply one sterile glove that was not on the fieldClean incision first using one of the appropriate cleaning techniques (hold cleaning container with non gloved hand). Bunch up the 4 x4 for cleaning the incision.Clean incision before drain siteWith gloved hand go into field and apply second gloveApply dressing (gauze, drain sponge, gauze on top of drain sponge, abd. pads)Secure dressing with tape (make a tab for easy removal)
55DEBRIDEMENT – this is a review Sharp debridement-Removal of necrotic tissue with a sterile scissors.Enzymatic debridement-Use of a topical chemical substance that breakdown and liquefy wound debris.Autolytic debridement-Painless, natural physiologic process that allows the body’s enzymes to soften, liquefy, and release devitalized tissueMechanical debridement-Use of wet-dry dressing to remove debris
56FACTORS WHICH AFFECT WOUND HEALING Type of wound injuryExpanse or depth of woundQuality of circulationAmount of wound debrisPresence of infectionStatus of the client’s health
57HEALING- reviewFirst Intention Healing-Primary intention is a reparative process in which the wound edges are directly next to each other.Second Intention Healing-The wound edges are widely separated, leading to a more time-consuming and complex reparative process.Third Intention Healing-The wound edges are widely separated and are later brought together with some type of closure material.
59Lab Practice Personal Dressing Kits- keep all supplies Lab demonstration by instructorStep by StepSet up disposal bag for old dressingApply unsterile (clean) gloves and remove old dressing. (If dressing sticks, apply saline and remove with clean glove). Assess wound and drainage, discard dressing, remove and discard gloves.Perform hand hygieneSet up fieldApply items to field (only add one sterile glove, other will be put on from bedside)Lip solution (i.e. normal saline) to clean the woundApply one sterile glove that was not on the fieldClean incision first using one of the appropriate cleaning techniques (hold cleaning container with non gloved hand). Bunch up the 4 x4 for cleaning the incision.Clean incision before drain siteWith gloved hand go into field and apply second gloveApply dressing (gauze, drain sponge, gauze on top of drain sponge, abd. pads)Secure dressing with tape (make a tab for easy removal)