1. SKILLS
NUR 124IN
Week 11

2. Patient-Centered Care
Minimize the onset and spread of infection to the patient through:
Medical asepsis: Procedures used to reduce the number of and prevent the spread of microorganisms.
Surgical asepsis: Procedures used to eliminate all microorganisms from an area. 2

3. Safety Standard precautions:
Any patient may be a source for infection.
Body substances contain potentially infectious organisms.
Fundamental to standard precautions is the use of barrier protection (use of personal protective equipment [PPE]). 3

4. Medical Asepsis Principles
Practice hand hygiene consistently.
Know a patient’s susceptibility to infection.
Recognize the elements of the chain of infection.
Use the basic principles of asepsis.
Protect against exposure to infectious agents through proper use and disposal of equipment.
Be aware of sites where health care–associated infections are most likely to develop. 4

5. Surgical Asepsis Principles
All items used within a sterile field must be sterile.
A sterile barrier compromised by punctures, tears, or moisture is considered contaminated.
Once a sterile package is opened, a 2.5-cm (1- inch) border around the edges is considered unsterile.
Tables draped as part of a sterile field are considered sterile only at table level.
If there is any doubt about the sterility of an item, the item is considered unsterile. 5

6. Surgical Asepsis Principles (cont’d)
Sterile persons or items contact only sterile items; unsterile persons or items contact only unsterile items.
Movement around and in the sterile field must not compromise or contaminate it.
A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated.
A sterile object or field becomes contaminated by prolonged exposure to air.
Stay organized and complete any procedure as soon as possible. 6

7. Hand Hygiene
Perform handwashing with either plain soap and water or an antimicrobial soap and water.
When hands are visibly dirty or soiled with blood or other body fluids, before eating, and after using the toilet
If hands are exposed to spore-forming organisms such as Clostridium difficile or Bacillus anthracis 7

8. Hand Hygiene (cont’d)
If hands are not visibly soiled, use an alcohol- based hand rub:
Before and after direct contact with patients
Before touching an invasive device
After contact with body fluids or excretions, mucous membranes, or nonintact skin
When moving from a contaminated to a clean body site during patient care
After contact with inanimate objects such as medical equipment near the patient
After removing gloves 8

9. Applying Personal Protective Equipment
Cap:
Prevents hair from contaminating sterile field.
Gloves:
Prevent contact with mucous membranes, nonintact skin, blood, body fluids, or other infectious material.
Mask:
Prevents inhalation/exhalation of microorganisms.
Eyewear:
Protects eyes against splashing of body fluids.
Gown:
Prevents transmission of and exposure to body fluids. 9

10. Preparing a Sterile Field
A sterile field is an area free of microorganisms and may include a sterile kit or sterile drapes.
Instruct patient not to move or touch sterile area.
Check sterile package for integrity or compromise.
Keep sterile field and items above waist level.
Do not reach over a sterile field.
If a sterile object touches an nonsterile object, it becomes contaminated.
Prevent splashing of poured liquids resulting in contamination of field. 10

11. Sample question
While setting up a sterile field for a procedure, the nurse knocks a linen-wrapped sterile package to the floor. To maintain safe practice, the nurse must:
A. Record the procedure as clean instead of sterile.
B. Carefully inspect the package for tears before opening.
C. Brush any visible contaminants from the package before opening.
D. Get a replacement for the package before continuing with the set up.

12. Correct response
D. Get a replacement for the package before continuing with the set up
Rationale: “linen wrapped” sterile package, landing on the floor could allow contaminants to penetrate the sterile area.
If the procedure is to be sterile, deciding to consider it “clean” would not be following the order as written and put the patient at risk.
Linen wrapped package would not show “tears”
Microorganisms are not visible to the eye, therefore brushing off “visible” contaminants does not assure sterilility.

13. Sterile Gloving
Sterile gloves act as a barrier against transmission of microorganisms.
Select correct glove size and type (latex or nonlatex).
Perform hand hygiene.
Open sterile glove package above waist level.
Identify right and left glove.
Glove dominant hand first.
Glove nondominant hand; do not contaminate dominant hand.
Interlock fingers and keep hands above waist and below shoulder level until procedure begins 13

14. Applying sterile gloves.B C D
Applying sterile gloves. 14

16. Patient-Centered Care
Wound assessment is the first essential step in planning wound care
Discuss the importance of wound assessments with patient and family.
Consider cultural beliefs and practices.
Maintain patient privacy during assessment and wound care.
Value and apply patient expertise in wound management.
Include care providers in wound management. 16

17. Safety
Use proper infection control practices to reduce the risk of wound infection.
Surgical wounds usually require sterile technique.
Chronic wounds often use clean technique.
Prevent tissue injury when measuring wounds.
Irrigate wounds gently.
User correct instruments when removing staples or stitches. 17

18. Performing a Wound Assessment
Assess wound status and phase of healing.
Frequency depends on condition of wound, health care setting, and agency policy.
Use agency-approved assessment tool.
Assess pain at wound site.
Measure dimensions: Undermining, tissue loss, tissue type, exudate, periwound skin.
Reapply dressing per order.
Record findings and compare to previous data. 18

19. Performing Irrigation
Cleanse surgical or chronic wounds using prescribed irrigating solution.
Position patient so solution flows away from wound.
Use appropriate syringe or equipment to minimize tissue trauma and provide gentle irrigation.
Apply slow, continuous pressure with syringe and/or catheter.
Use pulsatile high-pressure lavage per provider order.
Reapply appropriate dressing and label. 19

20. Managing Drainage Evacuation
Drainage devices apply suction to remove and collect drainage and facilitate wound healing.
They are inserted into wounds through the suture line or a small stab wound near the surgical site.
Number drainage devices when more than one exists.
Empty and reset drainage devices when more than one-half full.
Maintain asepsis when opening and closing system.
Measure and record volume and characteristics.
Reestablish vacuum by compressing or reattaching to suction. 20

21. Removing Staples and Sutures
Remove sutures or staples per provider order when surgical healing is adequate.
Sutures and staples usually removed in 7 to 10 days
Retention sutures left in longer (14 days or more)
Cleanse incision with antiseptic swabs.
Remove staples without scratching skin.
Remove suture with forceps after snipping.
Never snip both ends of a suture.
Identify type of suturing (e.g., interrupted, continuous).
Determine that all sutures are removed.
Cleanse incision with antiseptic.
Apply steri-strips according to policy or order. 21

22. A Staple extractor placed under staple
A Staple extractor placed under staple. B Removal of interrupted sutures. 22

23. Obtaining Wound Drainage Specimens for Culture
Wounds with signs and symptoms of infection require collection of drainage for culture.
Fresh exudate from the wound center should be collected after removing old drainage.
Aerobic organisms grow in areas exposed to air.
Coat swab with fresh secretions from wound.
Anaerobic organisms grow in areas where oxygen is not normally present.
Obtain specimen from deep cavity in wound.
Use special anaerobic culture tube. 23

24. Patient-Centered Care
Acute and chronic wounds can cause pain, distress, and financial burden on patients and families.
Consider individual patient needs, including socioeconomic needs.
Patients and families often care for wounds at home.
Initiate teaching as soon as possible.
Provide opportunities for patient and family participation. 24

25. Safety Wounds may be colonized with bacteria.
Colonization does not interfere with wound healing.
Monitor for signs of infection.
Wound infection interferes with wound healing.
Follow precautions to prevent introduction or spread of bacteria.
Wear personal protective equipment.
Follow agency isolation protocols for colonized or infected patients. 25

26. Applying a Dressing (Dry and Moist-to-Dry)
Dry dressings
For wounds healing by primary intention
Not used for debriding wounds
Moist-to-dry dressings
Commonly use isotonic solutions
Mechanically debride wounds
Provide pain medication if needed.
Remove tape by pulling toward dressing.
Remove dressing one layer at a time
If dry dressing sticks, moisten with normal saline. 26

27. Applying a Dressing (Dry and Moist-to-Dry) (cont’d)
Observe wound characteristics.
Prepare and maintain sterile field during dressing.
Clean wound from least to most contaminated area.
Gently pack moist-to-dry dressing.
Ensure that all dead space is loosely packed.
Do not leave moist gauze in contact with surrounding skin.
Blot dry sterile wound with sterile gauze to dry skin.
Cover with secondary dressing.
Secure with tape or Montgomery straps. 27

28. Applying a Pressure Bandage
Pressure bandages temporarily control excessive bleeding.
Locate external bleeding site.
Apply immediate manual pressure with gloved hand and dry gauze.
Obtain assistance from second person to prepare gauze compress and tape strips.
Tape compress with overlapping strips.
Keep firm pressure on site while taping.
Avoid tourniquet effect.
Observe dressing for control of bleeding. 28

29. Applying a Transparent Dressing
Occlusive or moisture-retentive dressings cover and encapsulate wounds.
Remove old dressing.
Pick up ends and slowly pull back parallel to wound.
Do not pull upward.
Cleanse and dry wound per orders.
Inspect wound characteristics.
Apply new dressing.
Do not stretch film.
Avoid wrinkles.
Smooth and adhere dressing with fingers. 29

30. Applying Gauze and Elastic Bandages
Use to wrap or secure hard-to-cover areas or exert pressure over a body part.
Apply from distal point toward proximal boundary, stretching slightly.
Alternate ascending and descending turns.
Ensure that bandage is snug but not tight.
Check primary dressing or splint for correct position.
Secure with tape or clips.
Assess tightness and routinely evaluate distal circulation. 30