Intro to Sterility and Documentation ppt

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.