Questions and Answers
What is the primary goal of aseptic technique in a clinical setting?
Where is the sterile field located when preparing for a procedure?
Which area is considered contaminated during a surgical procedure?
What should a provider do if they believe they have broken sterility during a procedure?
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When creating your own sterile field, which action is essential after wearing sterile gloves?
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What is essential to do before touching any supplies on the sterile field?
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Which of the following is an example of creating a sterile field?
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Which factor can significantly contribute to microbial contamination during medical procedures?
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What is the first component to include in the admission orders after trauma surgery?
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Which of the following components is NOT included in the admission orders?
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What is the appropriate term to describe the patient's health state in the admission orders?
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In the hospital charting, what does 'S/P' stand for?
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Which of the following must be documented in the bedside procedure notes?
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What should be included in the discharge summary under the condition at discharge?
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What part of the hospital charting service includes physical examinations following surgery?
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Which component is most crucial for documenting patient safety during procedures?
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Study Notes
Rationale for Aseptic Technique
- Major source of microbial contamination is the human body.
- Aseptic technique reduces shedding and controls the environment.
- Goals include minimizing organism transmission:
- From provider to patient
- From patient to provider
- From patient to themselves
Sterile Field Definition
-
You:
- Front of the gown from chest to waist (not near the mouth).
- Gloved hands and arms up to the elbows.
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Patient:
- Draped area down to the OR table.
- Anything below the patient table level is considered contaminated.
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Sterile Field:
- Covered portion of the Mayo stand (most used instruments).
- Top of the Back Table for additional instruments; sides are not sterile.
- Disposable light handles are part of the sterile field.
Key Practices for Sterility
- Always ask before touching an uncertain item.
- If sterility is broken, inform team members immediately.
- Example from experience: re-gloving is a common occurrence.
Creating Your Own Sterile Field
- Necessary for procedures in various settings, including:
- Wound suturing
- Chest tube insertion/thoracentesis
- Central line placement
- Biopsies
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Gathering Materials:
- Procedures may require specific kits or individually gathered supplies.
- For example: Pigtail Chest Tube.
- Creating a sterile field involves establishing a clean area and placing supplies onto it.
Procedure Preparation
- Wear sterile gloves and gown.
- Select the procedure site.
- Position and clean the patient.
- Drape the site after preparing.
Documentation in Clinical Settings
- Familiarize with admission orders in trauma situations. Key components include:
- Admit to service/team
- Attending physician's name
- Diagnosis and condition (stable/unstable)
- Vitals frequency
- Activity levels
- Allergies and specific nursing procedures
- Diet (e.g., NPO or soft diet)
- Intake and Output (I&O)
- Medication orders for daily, PRN, and symptomatic medications
- Labs/diagnostics and consultation requests
Hospital Charting
- Medical Service Charting:
- "Daily Notes" or "Progress Notes" structure:
- Hospital day, admission reason, S, O, A, P.
- "Daily Notes" or "Progress Notes" structure:
- Surgery Service Charting:
- "Post Op" or "Progress Notes":
- Post-op day (POD), status post (S/P) procedures, subjective findings, vital signs, and pe findings.
- Evaluate all relevant body systems post-surgery (DVT, wound status).
- "Post Op" or "Progress Notes":
Bedside Procedure Notes
- Document details for procedures including:
- Indications and informed consent.
- Time out confirmation.
- Description of the procedure including positioning, prep, and anesthesia.
- Details on sutures, complications, and estimated blood loss (EBL).
- Disposition and follow-up education.
Discharge Summary Components
- Include essential information such as:
- Admission and discharge dates.
- Admitting and discharge diagnoses.
- Attending physician and procedures performed.
- Relevant history, physical exam findings, and lab results.
- Condition upon discharge, disposition, and discharge medications.
- Detailed discharge instructions and follow-up plans.
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Description
This quiz explores the rationale behind aseptic techniques in clinical settings and the definition of sterile fields. It emphasizes key practices to maintain sterility and reduce microbial contamination during medical procedures. Test your knowledge on essential guidelines that ensure safety in healthcare environments.