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Nursing
Sterile Technique II
| Question | Answer |
|---|---|
| Delayed Wound healing due to | Age, malnutrition, obesity, hypoxia, smoking, drugs (steroids), DM, radiation, anemia, cancer, renal insufficiency, hypovolemia, immune system compromise, surgery >3 hrs |
| Complications | Hemorrhage & interstitial fluid loss (shock). Hematomas (blood tumor), infection, fistula formation, dehiscence, evisceration. |
| Purpose of a dressing | Protection, aiding hemostasis, promoting healing, supporting or splinting wound site, promoting thermal insulation, providing moist environment |
| Purpose of a bandage | Creating pressure over a body part. Immobilizing body part. Supporting a wound, reducing or preventing edema, securing a splint, securing a dressing, usually rolled gauze, kerlix, kling, and ace wrap |
| Before applying a bandage | Inspect skin. Cover exposed wounds or open abrasions with sterile dressing. Assess condition of underlying dressings and changing if soiled. Assess 5 P's of circulation |
| 5 P's of Circulation | Assess the skin of areas distal to the bandage for: pallor, paresthesia, pain, pulselessness, paralysis |
| Key concepts | Bandages need not be sterile. Wrap tight enough to hold without constricting blood flow. Avoid bandaging over wrinkled dressing to prevent pressure. Avoid bandaging over soiled dressings. Apply distal to proximal to facilitate venous return. |
| Things to remember | When applying a straight binder for support make sure to apply it while pt is lying in the bed. When using slings fasten off center behind the neck to avoid rubbing on the cervical vertebra. Unclean bandages & binders may cause infection. |
| Things to remember again | Prolonged heat & moisture on skin may cause epithelial cells to deteriorate. Place and support body part to be bandaged in normal functioning position. Place pins or knots well away from wound. |
| Heat Application | Causes vasodilation. Relieves pain from muscle spasms or injured joints. Promotes muscle relaxation. Can reduce swelling by increasing circulation. Eliminates toxic waste products that accumulate in swollen areas. |
| Uses for heat application | Surgical wounds, hemorrhoids, episiotomies, phlebitis, IV infiltration, arthritis, muscle spasms, cramps, low back pain |
| Methods of heat application | Aquathermia pads: Kpads, Therma-zone pads. Instant hot packs. Hot water bottles. Thermal warming blankets. Sitz baths. Warm soaks. |
| Cold application | Causes vasoconstriction. In early wound management: controls bleeding, edema, and reduces pain. |
| Uses for cold application | Fractures, laceration, muscle strains, arthritis, trauma, puncture wound, sprains, sports injury |
| Concerns related to heat and cold treatment | Age of pt, level of consciousness, circulatory impairment, sensory deficits, skin integrity, pt diagnosis, metallic implants. |
| Nursing Diagnoses | Risk for injury, pain, ineffective thermoregulation, hyperthermia, hypothermia |
Created by:
senmark
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