Intro to Sterility and Documentation ppt

Questions and Answers

What is the primary goal of aseptic technique in a clinical setting?

To maximize the number of staff involved

To minimize passing organisms between the provider and patient (correct)

To minimize equipment usage

To ensure all materials are sterile

Where is the sterile field located when preparing for a procedure?

The entire room where the procedure is performed

The patient’s entire body after draping

Front of the gown from chest to the waist and the top of the back table (correct)

Only the Mayo stand used for sterilized instruments

Which area is considered contaminated during a surgical procedure?

The gloved hands of the surgeon

Anything that falls below the level of the patient table (correct)

Draped part of the patient down to the OR table

Any instrument placed on the Mayo stand

What should a provider do if they believe they have broken sterility during a procedure?

Speak up immediately to address the issue Signup and view all the answers

When creating your own sterile field, which action is essential after wearing sterile gloves?

Draping the site to ensure cleanliness Signup and view all the answers

What is essential to do before touching any supplies on the sterile field?

Ask before touching something if unsure about sterility Signup and view all the answers

Which of the following is an example of creating a sterile field?

Establishing a sterile setup while performing a biopsy Signup and view all the answers

Which factor can significantly contribute to microbial contamination during medical procedures?

The provider's proximity to the patient Signup and view all the answers

What is the first component to include in the admission orders after trauma surgery?

Admission to [Service/Team] Signup and view all the answers

Which of the following components is NOT included in the admission orders?

Daily notes Signup and view all the answers

What is the appropriate term to describe the patient's health state in the admission orders?

Condition Signup and view all the answers

In the hospital charting, what does 'S/P' stand for?

Status Post Signup and view all the answers

Which of the following must be documented in the bedside procedure notes?

Estimated blood loss Signup and view all the answers

What should be included in the discharge summary under the condition at discharge?

Improvement status Signup and view all the answers

What part of the hospital charting service includes physical examinations following surgery?

Progress notes Signup and view all the answers

Which component is most crucial for documenting patient safety during procedures?

Informed consent Signup and view all the answers

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.
Patient:
- Draped area down to the OR table.
- Anything below the patient table level is considered contaminated.
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
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.
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).

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.