Surgical Asepsis
Published on Mar 20, 2016
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PRESENTATION OUTLINE
LAYERS OF THE SKIN
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Aging and the Skin
Newborn: neonates skin is relatively immature at birth, and very thin, therefore friction can cause bruising very easily-so handle them very carefully during bathing, as any break in skin can lead to infection
Adults: depends on hygiene practices—so we have a lot of responsibility here as educators. Starts to lose some resilency and moisture.
Elderly: The skin becomes more fragile and subject to bruising and breaking and damage-especially because of shearing forces— Becomes more dry and wrinkled, excessively dry. Avoiding hot water and frequent baths. Skin pigmentation increases unevenly, causing discolored areas. Skin loses elasticity, skin lesions appear as skin tags, warts etc.
Polypharmacy and concurrent medical conditions interfere with wound healing. The attachment between the epidermis and the dermis becomes flattened in older adults, which allows the skin to be easily torn in response to mechanical trauma (tape removal).—even nursing scissors can hurt—tell story of student in cardiac this spring. Slow wound healing, less subcutaneous padding under the dermis, especially over bony prominences, so very prone to skin breakdown. Reduced nutritional intake increases risk for pressure ulcers and impaired wound healing.
Adults: depends on hygiene practices—so we have a lot of responsibility here as educators. Starts to lose some resilency and moisture.
Elderly: The skin becomes more fragile and subject to bruising and breaking and damage-especially because of shearing forces— Becomes more dry and wrinkled, excessively dry. Avoiding hot water and frequent baths. Skin pigmentation increases unevenly, causing discolored areas. Skin loses elasticity, skin lesions appear as skin tags, warts etc.
Polypharmacy and concurrent medical conditions interfere with wound healing. The attachment between the epidermis and the dermis becomes flattened in older adults, which allows the skin to be easily torn in response to mechanical trauma (tape removal).—even nursing scissors can hurt—tell story of student in cardiac this spring. Slow wound healing, less subcutaneous padding under the dermis, especially over bony prominences, so very prone to skin breakdown. Reduced nutritional intake increases risk for pressure ulcers and impaired wound healing.
Photo by VinothChandar
Phases of Wound Healing
Photo by ChristyInsDesign
Primary Intention
Secondary Intention
Tertiary Intention
Primary Intention
So we say that there is little tissue loss, but skin edges are approximated, or closed, and the risk of infection is low. Healing occurs quickly, with minimal scar formation, as long as infection and secondary breakdown is prevented. Ex: surgical incisions, wound that is sutured or stapled, first degree burn, scratch etc
Secondary Intention
secondary intention wounds that are left open and allowed to heal by scar formation ; tissue loss and open wound edges with granulation tissue gradually filling area of defect; typical of severe laceration or massive surgical intervention with skin loss, gap between edges
secondary intention, in which the wound is left open and closes naturally; and third intention, in which the wound is left open for a number of days and then closed if it is found to be clean.
secondary intention, in which the wound is left open and closes naturally; and third intention, in which the wound is left open for a number of days and then closed if it is found to be clean.
Tertiary Intention
tertiary intention "delayed primary intention or closure" ; surgical wounds left open for 3-5 days to allow edema or infection to diminish before wound edges are sutured or stapled closed ; minimal scarring with wound usually covered with dressing
Phases of Wound Healing
- Inflammatory phase
- Proliferative phase
- Remodelling phase
#1: is beneficial because bacteria is ingested , wound is cleansing, bleeding is controlled. What does the wound look like in this phase? Localized redness, edema, warmth and throbbing.
#2: filling of the wound with granulation and replacement tissue, wound contracts, surface is repaired
#3: scar continues to reorganize, and gain strength, and take on lighter color.
#2: filling of the wound with granulation and replacement tissue, wound contracts, surface is repaired
#3: scar continues to reorganize, and gain strength, and take on lighter color.
Photo by solene MeSt*
PRESSURE ULCERS
Wound Assessment
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- assess pain prior
- assess baseline traits
- watch for complications
- inspect thoroughly
In depth wound assessment (deep palpation) is only done by physicians. Debridement is an advanced skill as well
Observe S&S of pain and administer prn medications at least 30 minutes prior to assessment +/or exposing the wound
Baseline wound assessment is important to observe improvements/lack of improvement with wound healing and is completed with every dressing change or PRN
Watch for complications (hemorrhage, infection, dehiscence, evisceration, fistulas)
Observe S&S of pain and administer prn medications at least 30 minutes prior to assessment +/or exposing the wound
Baseline wound assessment is important to observe improvements/lack of improvement with wound healing and is completed with every dressing change or PRN
Watch for complications (hemorrhage, infection, dehiscence, evisceration, fistulas)
Assess Open Wound Appearance
- wound appearance: size, depth,drainage, colour,location
- undermining? tunnelling?
- odor?
If open wound:
Size of the wound: width & length (use metric measurements)
Depth of wound?
Drainage? Type of drainage
Color of tissue-red, pink/purple, yellow (slough), black/brown (eschar)
slough is a yellow fibrinous tissue that consists of fibrin, pus, and proteinaceous material. Slough can be found on the surface of a previously clean wound bed and it is thought to be associated with bacterial activity.
undermining: Separation of tissue from the surface under the edge of the wound.
Describe by clock face with patients head at 12 (“undermining is 1 cm from 12 to 4 o’clock”)
Tunneling
Channel that runs from the wound edge through to other tissue
“tunneling at 9 o’clock, measuring 3 cm long”
Size of the wound: width & length (use metric measurements)
Depth of wound?
Drainage? Type of drainage
Color of tissue-red, pink/purple, yellow (slough), black/brown (eschar)
slough is a yellow fibrinous tissue that consists of fibrin, pus, and proteinaceous material. Slough can be found on the surface of a previously clean wound bed and it is thought to be associated with bacterial activity.
undermining: Separation of tissue from the surface under the edge of the wound.
Describe by clock face with patients head at 12 (“undermining is 1 cm from 12 to 4 o’clock”)
Tunneling
Channel that runs from the wound edge through to other tissue
“tunneling at 9 o’clock, measuring 3 cm long”
Assess Open Wound Appearance
- Necrotic tissue or slough present?
- Assess granulation tissue
Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process.[1] Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size.
light red or dark pink in color, being perfused with new capillary loops or "buds";
soft to the touch;
moist; and
bumpy (granular) in appearance. painless
so assess if it is (dry/moist,
pale/fragile?)
light red or dark pink in color, being perfused with new capillary loops or "buds";
soft to the touch;
moist; and
bumpy (granular) in appearance. painless
so assess if it is (dry/moist,
pale/fragile?)
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Assess Primary Intention Wounds
- Are edges well approximated and clean
- Any drainage?
- Any inflammation?
- Any dehiscence and/or evisceration
Any drainage? (present for more than 3 days after closure?)
Inflammation around edges of wound? (present after 3 days?)
Inflammation around edges of wound? (present after 3 days?)
For all Wounds:
ASSESS PERI-WOUND AREA
(outside the wound) for redness, edema, dryness, maceration, scaling, open areas, irritation.
Assess Wound drainage
- odor
- amount
- type
- consistency
always remember to look at old dressing
Odor: foul/strong odor = infection. Various bacteria will have a distinct smell.
Amount : Scant, Small, Moderate, Large, Copious (also relates to size of wound)
Types : Serous (clear, watery plasma) Sanguineous (blood; bright =fresh bleeding, dark = older bleeding), Purulent (thick, contains pus, green, yellow, brown,
Combos: serousanguineous, sanguipurulent, seropurulent
Consistency: thick, watery….
Odor: foul/strong odor = infection. Various bacteria will have a distinct smell.
Amount : Scant, Small, Moderate, Large, Copious (also relates to size of wound)
Types : Serous (clear, watery plasma) Sanguineous (blood; bright =fresh bleeding, dark = older bleeding), Purulent (thick, contains pus, green, yellow, brown,
Combos: serousanguineous, sanguipurulent, seropurulent
Consistency: thick, watery….
WOUND DRAINS/CLOSURES
A drain is often inserted in or near a surgical wound to collect wound drainage and you will learn about these and how to care for them later
Surgical wounds are closed with staples, sutures, or wound closures and you learn about these and how to care for them later
Surgical wounds are closed with staples, sutures, or wound closures and you learn about these and how to care for them later
WOUND CULTURES
If you suspect infection, obtain a specimen of the drainage for culture.
Never collect a specimen from old drainage. Clean site first with normal saline or sterile water, and obtain sample with sterile swab from a culturette tube. Rotate the swab in the wound, and apply a bit of pressure to elicit tissue fluid.
we usually only culture deep wounds, superficial wounds they usually will try a topical treatment first and if that doesn’t work, then swab.
Never collect a specimen from old drainage. Clean site first with normal saline or sterile water, and obtain sample with sterile swab from a culturette tube. Rotate the swab in the wound, and apply a bit of pressure to elicit tissue fluid.
we usually only culture deep wounds, superficial wounds they usually will try a topical treatment first and if that doesn’t work, then swab.
SIGNS OF INFECTION
Failure to heal
Induration (hardening)
Pale boggy granulation tissue
Increased WBC’s
Undermining
Delayed healing
Deep structure involvement
Host factors(Age,Obesity,
Impaired Oxygenation, Smoking,Medications
Diabetes,Radiation)
Wound Stress (Ex CABG)
change in odor, volume or character of wound drainage
Redness/warmth in surrounding tissue
Fever
Ongoing pain
Induration (hardening)
Pale boggy granulation tissue
Increased WBC’s
Undermining
Delayed healing
Deep structure involvement
Host factors(Age,Obesity,
Impaired Oxygenation, Smoking,Medications
Diabetes,Radiation)
Wound Stress (Ex CABG)
change in odor, volume or character of wound drainage
Redness/warmth in surrounding tissue
Fever
Ongoing pain
Complications of Wound Healing
- Hemorrhage
- Infection
- Dehisence
- Evisceration
- Fistulas
#1: internal hemorrhage: look for swelling/mass, change in color, temp change in the type of drainage and amount. (One of the reasons why we chart how many dressings we use and what we use). External:obvious. (decreased RBC’s, HgB…)
#2: prohibits wound healing
#3: poor nutrition, obesity, infection
#4: protrusion of internal organs through wound opening. Quickly place sterile towels soaked in sterile saline over the extruding tissues-client NPO, observe for signs of shock which you will learn in NURS 4121. Prepare for surgery.
#5: abnormal passage between two organs or between an organ and the outside of the body.
#2: prohibits wound healing
#3: poor nutrition, obesity, infection
#4: protrusion of internal organs through wound opening. Quickly place sterile towels soaked in sterile saline over the extruding tissues-client NPO, observe for signs of shock which you will learn in NURS 4121. Prepare for surgery.
#5: abnormal passage between two organs or between an organ and the outside of the body.
DRESSINGS
Purposes of Dressings
- Allow enzymes in the wound fluid to digest the eschar and slough
- Some dressings support a moist wound bed and at the wound surface
- Absorbent dressings prevent an excess of exudate
#3: why would we not want an excessive amoutnt of exudate in the wound.> This amount would promote bacterial growth (remember medical asepsis class last year—they like the dark, warmth and moisture---oooo bacteria would have a party under that dressing. The exudate also hurts healthy skin—so the peri-wound area you be altered. Too much exudate also slows the healing process.
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- Protects the wound from microorganism contamination
- Aids in hemostasis
- Supports or splints the wound site
- Protects the client from seeing the wound
#2: stops bleeding
TYPES OF DRESSINGS
Telfa (#1: non stick—but does not hold the drainage well—allows the drainage to come to the guaze or dry dressing above it. Because of its low ability to absorb drainage—only for wounds that have little to no drainage. Often used with surgical incision lines).
Woven guaze dressings (#2: useful as a packing material (make sure to document how many you used—tell stories here). Available in all different sizes. It can be saturated with solutions and packed in wounds. Or nu-guaze can also be packed in a wound as well. Depending on the size. If the wound is very dry we can soak the guaze in hydrogel which helps to moisten the wound. We often use the bigger sizes of guaze as a cover with wounds with drainage as well.
Transparent film dressings ( they are self-adhesive, and occlusive. It traps the wound’s moisture over the wound, providing a moist environment. Canalso be used for small superficial wounds, or for protection of susceptible skin. However, they can be difficult to remove-especially to fragile skin. It can be useful to affix guaze. Nice because you can see the wound through it—if just using this.
Soft silicone dressings(Soft silicone dressings are coated with a hydrophobic soft silicone layer
that is tacky to touch. These dressings do not stick to the moist wound
bed, but will adhere gently to the surrounding skin. They are designed
to minimise trauma on removal and do not leave an adhesive residue
on the skin) meplix
Hydrocolloid dressings e.g. duodenum ,tegaderm hydrocolloid)(The moist conditions produced under the dressing are intended to promote fibrinolysis, angiogenesis and wound healing, without causing softening and breaking down of tissue.
Hydrogel dressings (Amorphous hydrogel, formulated to help provide a moist wound healing environment that has been shown to enhance wound healing. Available in single-dose tubes swell)
And the list goes on…
Woven guaze dressings (#2: useful as a packing material (make sure to document how many you used—tell stories here). Available in all different sizes. It can be saturated with solutions and packed in wounds. Or nu-guaze can also be packed in a wound as well. Depending on the size. If the wound is very dry we can soak the guaze in hydrogel which helps to moisten the wound. We often use the bigger sizes of guaze as a cover with wounds with drainage as well.
Transparent film dressings ( they are self-adhesive, and occlusive. It traps the wound’s moisture over the wound, providing a moist environment. Canalso be used for small superficial wounds, or for protection of susceptible skin. However, they can be difficult to remove-especially to fragile skin. It can be useful to affix guaze. Nice because you can see the wound through it—if just using this.
Soft silicone dressings(Soft silicone dressings are coated with a hydrophobic soft silicone layer
that is tacky to touch. These dressings do not stick to the moist wound
bed, but will adhere gently to the surrounding skin. They are designed
to minimise trauma on removal and do not leave an adhesive residue
on the skin) meplix
Hydrocolloid dressings e.g. duodenum ,tegaderm hydrocolloid)(The moist conditions produced under the dressing are intended to promote fibrinolysis, angiogenesis and wound healing, without causing softening and breaking down of tissue.
Hydrogel dressings (Amorphous hydrogel, formulated to help provide a moist wound healing environment that has been shown to enhance wound healing. Available in single-dose tubes swell)
And the list goes on…
SECURING DRESSINGS
Tape, ties, self-adhering dressings, or a secondary dressing and cloth binders or guaze net.
Choice depends on wound size and location, presence of drainage, the frequency of dressing changes, and the patient’s level of activity.
Tape is hard on fragile skin…
Does the patient have an allergy to tape or adhesives?
What about the periwound skin area?
Come in various widths, and can be already perforated for ease of tearing
When applying tape: skin should be dry, exert pressure away from the wound, never applied to irritated or broken skin.
When removing: loosen the tape ends, and gently pull toward the wound while applying light traction to the skin away from the wound. With hair, pull in direction of hair growth if possible
Choice depends on wound size and location, presence of drainage, the frequency of dressing changes, and the patient’s level of activity.
Tape is hard on fragile skin…
Does the patient have an allergy to tape or adhesives?
What about the periwound skin area?
Come in various widths, and can be already perforated for ease of tearing
When applying tape: skin should be dry, exert pressure away from the wound, never applied to irritated or broken skin.
When removing: loosen the tape ends, and gently pull toward the wound while applying light traction to the skin away from the wound. With hair, pull in direction of hair growth if possible
Documenting Dressing Changes
- What about the old dressing?
- What do you see on the old dressing?
- Now for the wound…
#1—was it intact or non-intact, did you see drainage from the outside. Was it a good choice—although we cant chart this is not a good choice fro the patient for legal reasons, we can chart what we see and advocate for something else.
#2: type, amount, characteristics of wound drainage, or absence of. How did the patient tolerate the dressing removal---don’t forget to care for the patient and the wound
#3: tissue appearance, size, color, amount type and consistencyof drainage, odor?, bleeding, periwound tissue, what was present (drain, sutures, staples—and how many?) Any dressings stick to the wound? How did you get it off?underminning? Tunnelling?
#2: type, amount, characteristics of wound drainage, or absence of. How did the patient tolerate the dressing removal---don’t forget to care for the patient and the wound
#3: tissue appearance, size, color, amount type and consistencyof drainage, odor?, bleeding, periwound tissue, what was present (drain, sutures, staples—and how many?) Any dressings stick to the wound? How did you get it off?underminning? Tunnelling?
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- What did you use to clean and dress the wound?
- What about the patient?
#4:what exactly was the solution? Where to did you apply it? How many dressings did you use? What types of dressings used—be very specific. Did you date your dressing—although not in documenation. Why would we date the dressing????
#5: How did the patient tolerate this dressing change? Any comments or verbalizations from the patient that would need documenting?
#5: How did the patient tolerate this dressing change? Any comments or verbalizations from the patient that would need documenting?
Preparing for the Dressing Change
- Analgesics
- Describe the procedure
- Gather all necessary supplies
- Make sure you make yourself aware of signs of normal healing and signs of infection
- Prepare yourself
#1: about 30 minutes before a dressing change unless you have a faster acting pain medication.
#2: and do not lie—if it is going to hurt—they need to know. Prepare them for what to see and be honest when they ask about how it looks—has it improved?
#2: and do not lie—if it is going to hurt—they need to know. Prepare them for what to see and be honest when they ask about how it looks—has it improved?
Basic Cleaning Techniques
- Generally use sterile guaze
- Only one swipe per gauze
- cleanse in direction from wound to surrounding skin (least contaminated to most contaminated)
see figures in text for direction of cleanse
SURGICAL ASEPSIS
AKA: sterile technique.
Includes procedures used to eliminate all microorganisms
An area or object is considered contaminated if touched by any object that is not sterile (even the slightest break)
We use surgical asepsis for: perforating of the skin, when skin’s integrity is broken, insertion of catheters, or surgical instruments into sterile body cavities
So we need to be explaining to our patient about the need to keep everything sterile before the procedure, so we can avoid them helping to contaminate our sterile objects, field etc. So they need to know to not make sudden movements, what not to touch, avoid coughing sneezing or talking over sterile area.
Includes procedures used to eliminate all microorganisms
An area or object is considered contaminated if touched by any object that is not sterile (even the slightest break)
We use surgical asepsis for: perforating of the skin, when skin’s integrity is broken, insertion of catheters, or surgical instruments into sterile body cavities
So we need to be explaining to our patient about the need to keep everything sterile before the procedure, so we can avoid them helping to contaminate our sterile objects, field etc. So they need to know to not make sudden movements, what not to touch, avoid coughing sneezing or talking over sterile area.
Principles of Surgical Asepsis
- 1) a sterile object remains sterile only when touched by another sterile object
- 2) only sterile objects can be placed on a sterile field
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- 3) a sterile object or field out of the range of vision or an object held below a person’s waist is contaminated
- 4) a sterile object or field becomes contaminated by prolonged exposure to air
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- 5) when a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action.
- 6) the edges of a sterile field or container are considered to be contaminated.
- 7) fluid flows in the direction of gravity
Surgical Asepsis
- Opening a sterile field…
- Pouring sterile solutions…
- Applying sterile gloves (open gloving)…
#1: go over procedure
#2: never rest it on a sterile surface. Pour with label facing palm to avoid liquid fading label. Make sure it is the right solution—and show how to pour multiple solutions in the tray.
#3: see page 672
#2: never rest it on a sterile surface. Pour with label facing palm to avoid liquid fading label. Make sure it is the right solution—and show how to pour multiple solutions in the tray.
#3: see page 672
SIMPLE STERILE DRESSING TECHNIQUE...
go over technique
