Aseptic Technique PDF

NURS N103F Fundamental Nursing Practice Aseptic technique I  Learning outcomes Upon completion of the class, students should be able to: Identify the different types of wounds: Discuss the 4 phases of wound healing; Discuss factors affecting wound healing; Identify various wou...

NURS N103F Fundamental Nursing Practice Aseptic technique I  Learning outcomes Upon completion of the class, students should be able to: Identify the different types of wounds: Discuss the 4 phases of wound healing; Discuss factors affecting wound healing; Identify various wound complications; Discuss the various dressing products; Apply principles of aseptic technique for wound dressing & wound packing  Consist of 2 layers ⚬ Epidermis ⚬ Dermis skin Epidermis: ⚬ protects underlying cells and tissue from dehydration ⚬ prevents entrance of certain chemical agents ⚬ allows evaporation of water from skin ⚬ permits absorption of certain topical Epidermis medication Dermis: ⚬ is the inner layer of skin, contains mainly Dermis connective tissue ⚬ collagen, blood vessels and nerves are found in this layer ⚬ protects the underlying muscle, bones and organs wound Definition Disruption of the integrity and Cause function of tissue in the body Can be result from: Varying in size, depth and severity mechanical force, e.g. surgery physical injury, e.g. burn Wound types  Open Wound Type Characterisitcs Separation of tissue with clean & smooth edges, Incision made surgically Separation of tissue with irregular & torn edges, Laceration made by traumatic injury Scarping away of surface layers of skin Abrasion traumatically Pointed object through skin or mucosal membrane Puncture and underlying tissue made by sharp  Close Wound Type Characterisitcs Contusion Tissue injury without breaking of skin Haematoma Damage the blood vessels, pooling of blood under the unbroken skin 4 Phases of wound healing  Haemostasis phase Control blood loss, establish bacterial control and seal the defect occurs when there is an injury ⚬ Injured blood vessels constricts ⚬ platelets gather to stop bleeding ⚬ fibrin matrix provides a framework for cellular repair  Inflammatory phase White cells move to the wound first ⚬ To ingest bacteria and cellular debris After ~24 hours, macrophages enter the wound area ⚬ To ingest bacteria ⚬ To release growth factors for the growth of epithelia cells and new blood vessels Characterized by redness, swelling, heat and pain  Proliferation phase Last for several weeks New tissue is built to fill the wound space Connective tissue cells (fibroblast) will synthesis and secret collagen and produce specialized growth factors A thin layer of epithelial cells forms across the wound The new granulation tissue forms the scar  Remodeling phase T Continue for months to years, depends on the depth and extent of the wound The collagen that was deposited in the wound is remodeled and contracted, making the healed wound stronger and alike adjacent tissue Scar tissue may be formed If scar is over a joint may limit movement and cause disability  Factors affecting wound healing Systemic factors Age General health condition (e.g. Diabetes mellitus) Circulation Nutritional status ⚬ Obesity is associated with an increased risk of ischemia and inadequate tissue oxygenation, ​which may lead to slowed wound healing or necrosis ⚬ Malnutrition (seen frequently in elderly patients), specifically inadequate protein intake, can lead to decreased blood vessel formation, collagen production, and fibroblasts proliferation, ​which ultimately slows the wound healing process.​  Factors affecting wound healing Systemic factors Life style (e.g. smoker) ⚬ the use of nicotine, affects blood flow by causing vasoconstriction. ​ Medications ⚬ Anti-inflammatory drugs that interfere with healing, e.g.​ NSAIDs (non- steroidal anti-inflammatory drugs) ​ ￭ NSAIDs are known to slow wound healing through the halting of angiogenesis.​​ ⚬ Immunosuppressant ​(e.g. steroids)​ Medical treatments ⚬ Radiation therapy​ ⚬ Chemotherapy​ ￭ slows down the rate of cell production can delay wound healing​  Factors affecting wound healing Local factors Pressure – disrupt blood supply to the wound​ ⚬ Persistent or excessive pressure interferes with blood flow to the tissue and delays healing.​ Desiccation (Dehydration)– cells dehydrate and die in dry environment which will delay healing​ ⚬ Wounds that are kept moist (not wet) enhance epidermal cell migration​ Maceration (Over-hydration) – prolonged exposure to moisture, ​ ⚬ may be due to urinary or faecal incontinence, causing change of pH, overgrowth of bacteria and infection of the skin​  Factors affecting wound healing Local factors Repeated trauma Edema ⚬ interfere with blood supply and resulting in an inadequate supply of oxygen and nutrients to the tissues​ Infection ⚬ toxins released by the bacteria interfere with wound healing and may cause cell death​ Excessive bleeding ​ ⚬ Large clots interfere with oxygens diffusion to the tissue, and promotes to growth of bacteria​ Necrosis​ delays wound healing​ Nutrition information to promote wound healing Key Reason Examples nutrients Meat, fish, dairy products (milk, yogurt), egg Protein Helps to maintain and repair body tissues Vegetarian: soya, soya product (tofu), nuts and seeds Iron is important for the healing process by Meat(beef, chicken), fish, tofu Iron helping to maintain adequate haemoglobin Beans, green vegetables (spinach, broccoli) level Vit C forms extra-bounds between collagen Citrus fruit (oranges, limes, grapefruit) Vit C fibers that increase stability and strength of Broccoli, spinach collagen matrix Zinc is important for DNA replication in cells Red meat, shellfish, milk, cheese Zinc and fibroblasts Pumpkin seed, beans and cereal products Classification of wounds based on the appearance  Epithelialising wound Final stage of wound healing Pink/ white in colour Occurs on top of healthy granulation tissue, barrier function of the skin is restored Treatment aim: ⚬ Creation of warm, moist environment ⚬ Prevent skin stripping and shearing damage  Granulating wound Generally red or dark pink bumpy tissue in the wound bed Bumpy appearance is the visible tops of the new capillary loops May have exudate Treatment aim: ⚬ To promote a warm, moist environment through balanced control of exudate  Slough Refers to yellow/white material in the wound bed It is usually wet but can also be dry Can be thick and adhered to wound bed Consists of dead cells that accumulate in the wound exudate Treatment aim: ⚬ Deslough to avoid infection, remove devitalized tissue and promote autolysis  Infected wound Usually accompanied by pain, inflammation, edema, odor, swelling or increased exudate result in non-healing wound More serious systemic complications can be induced Treatment aim: ⚬ Kill the bacteria which cause infection, topical antibiotics/ antimicrobial dressing can be used  Necrotic wound Dead or devitalized non-viable tissue which impedes wound healing Black, dry and leathery covering over the wound bed Treatment aim: ⚬ Has to be removed by debriding the wound to allow new tissue to form  Wound Undermining Occurs when significant erosion occurs underneath the outwardly visible wound margins It might be possible that the external wound appear small while large areas of tissue loss be detected underneath the surface Common wound complication Wound complications can interfere with wound healing Major complications include: a. Haemorrhage b. Infection c. Dehiscence d. Evisceration  Haemorrhage It can refer to blood loss (massive bleeding) in the wound Might be causes by a dislodged clot, slipped stitches, or erosion of a blood vessel Interventions: Frequent checking of the dressing Apply additional pressure dressing Fluid replacement therapy Surgical repair of the bleeding site  Wound Infection Wound infection is defined as the presence of bacteria or other organisms, which multiply and lead to the overcoming of host resistance Local indicators of infection: ⚬ Redness (erythema) ⚬ Oedema ⚬ Localised heat ⚬ Localised pain ⚬ Exudate ￭ a change to purulent fluid or an increase in amount of exudate ⚬ Malodor  Dehiscence A medical emergency Partial or total rupturing of a sutured wound Resulted from excessive stress on wounds that are not healed Usually involves an abdominal wound in which the layers below the skin also separate Intervention Cover the wound with sterile towels/ gauze moistened with sterile 0.9% sodium chloride solution Notify the doctor for immediate surgical repair is required  Evisceration The most serious complication of dehiscence The wound completely separates with protrusion of internal viscera through the incisional area Risk factors: obesity, poor nutrition, infected wounds, excessive coughing, vomiting, straining Interventions Place the patient at low Fowler’s position Covered the wound area with sterile towel/ gauze moistened with sterile 0.9% sodium chloride solution Notify doctor for immediate surgery repair required Pressure Injury  Pressure Injury A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device The injury can present as intact skin or and open ulcer and may be painful Most common site for pressure injury development is sacrum Bony Prominence at different position Etiology of Pressure Injury  Etiology of Pressure Injury ⚬ ⚬ Staging for Pressure Injury  Staging for Pressure Injury  Staging for Pressure Injury  Staging for Pressure Injury  Prevention of Pressure Injury  Wound assessment Wound assessment 1. Wound appearance 2.Presence of wound drain/ suture 3. Surrounding skin 4.Signs of infection 5. Wound pain Appearance of Wound Site Size Wound bed color Exudate  Wound Site Site of the wound, e.g. right big toe, right sole, left lower quadrant of abdomen  Wound Size Measure the wound with disposable measuring tape, use clock method to indicate Length: “head-to-toe” at the longest point (A) Width: side-to-side at the widest point that is perpendicular to the length (B) Depth: Deepest point of the wound For wound that approximately circular  Wound with undermining and tunneling Undermining Open area extending under intact skin along the edge of the wound Tunneling A narrow channel or passage? extending in any direction from the base of the wound. This results in dead space with a potential risk for abscess formation Determine direction & depth with dressing applicators  measurement for irregular wound Using a transparent acetate sheets to outline of the wound margin Add up the number of squares contained within the margin of the outline of the wound from an acetate grid tracing  Wound Drainage/ Exudate Exudate is also called wound drainage Fluid that accumulates in a wound may contain ⚬ serum ⚬ cellular debris ⚬ bacteria ⚬ white blood cells Exudate may become more viscous and odorous in infected wounds It is important to assess and document the type, amount, colour and odour of exudate to detect if there is any change in wound condition Excess exudate leads to maceration and degradation of skin while too little can result in the wound bed drying out  Type of Exudate Serous Sanguineous (bloody) Consist mainly Bloody wound serum (the serous drainage with portion of blood) little, if any, Looks clear and serous fluid. watery Indicate damage ⚬ E.g. fluid in a to capillaries that blister allow escape of RBCs from plasma Usually seen in open wounds  Type of Exudate Serosanguineous Purulent Consist of leukocytes Blood-stained (WBC), liquefied dead tissue wound fluid debris, and both dead & Mixture of serum living bacteria Purulent drainage is thick, and red blood cells often has a musty or foul Light pink to blood odor tinged Exudate can be amber, straw or green in colour When documenting about purulent drainage, the color and presence of odor needs to be indicated  Colour of wound bed Black indicate presence of necrotic might need debridement (removal) to promote wound healing Red Yellow proliferation stage of healing indicate presence need protection of drainage/ with gentle slough cleansing often accompanied with purulent drainage; requires wound cleansing  Wound drain Presence of Staples drain/ suture Stitches  Wound assessment Surrounding skin Signs of infection Wound edges may Hot on palpation appear reddened Increased drainage, and slightly possible purulent swollen, will return Separated wound edges to normal  Pain assessment Use pain assessment scale Measure and document the pain level before, during and after procedure  Diagnostic test related to wound healing Leukocyte count (WBC) ⚬ increase possibility of infection Haemoglobin level ⚬ indicates poor oxygen delivery to the tissues Blood coagulation study (clotting profile) ⚬ result in excessive blood loss and prolonged clot absorption Albumin ⚬ indicates poor nutrition, may delay wound healing Wound Culture ⚬ Obtain whenever wound infection is suspected ⚬ Helpful in the selection of antibiotic therapy ⚬ Obtain the specimen before antibiotic treatment  Aseptic technique  Definition The word “aseptic” literally means an absence of disease- causing microbes and pathogens Aseptic technique is a process or procedure purposeful reduction of pathogens to prevent the transfer of microorganisms from one person or object to another during a medical procedure Potentially infectious microscopic organisms can be present in the environment, on an instrument, in liquids, on skin surfaces, or within a wound  Principle of Aseptic Technique 1. All objects used in a sterile field MUST be sterile Always check sterile package for intactness, dryness and expiry date Expired sterile materials are considered as non-sterile Check chemical indicators of sterilization before use Sterile items should be stored at clean, dry, off the floor, and away from sink  Principle of Aseptic Technique 2. Sterile objects become unsterile when touched by unsterile objects Handle sterile objects only with sterile forceps or sterile gloved hands Whenever the sterility of an object is questionable, assume the object is unsterile  Principle of Aseptic Technique 3.Sterile items that are out of vision or below the waist or table level are considered unsterile Once left unattended, a sterile field is considered unsterile Always keep sterile object in view – DO NOT turn your back on a sterile field Always keep sterile gloved hands in sight and above waist/ table level  Principle of Aseptic Technique 4.Sterile objects can become unsterile by prolonged exposure to microorganisms Wear mask during a sterile procedure Refrain from reaching over the sterile field to prevent microorganisms from falling over to sterile field.  Principle of Aseptic Technique 5.Fluid flow in the direction of gravity Always hold the forceps pointing downwards 6. Moisture that passes through a sterile object draws microorganisms from unsterile surfaces to sterile surface by capillary action Use moisture-proof barriers Pour liquids into container on a sterile field carefully  Principle of Aseptic Technique 7.The edges of a sterile field are considered unsterile Leave a 1-inch margin  Principle of Aseptic Technique 8.Clean the wound in proper direction From top to bottom/ proximal to distal From inner to outer From clean to dirty One swab once Principle of Aseptic Technique From Clean to Dirty Application of nursing process in wound management  Assessment 1. Verify the medical prescription and patient's identity 2.Perform hand hygiene and approach patient 3.Verify patient's identity with name & hospital number against medical prescription 4.Check patient’s allergy history including cleansing lotion, dressing materials, adhesive tape 5.Explain the procedure to patient to obtain consent and cooperation 6.Provide privacy 7.Assess wound condition by gloved hands (please refer to previous slides) 8.Leave the old dressing in place after assessment 9. Assess patient's needs, e.g. need for analgesic or toilet ⚬ Allow sufficient time for analgesic to take effect Application of nursing process in wound management  Planning 1. Perform hand hygiene 2.Clean dressing trolley with 70% alcohol wipes in one direction 3.Gather all necessary equipment 4.Place sterile dressing set on the upper shelf of dressing trolley 5.Place other dressing supplies and prescribed cleansing solution on the lower shelf of dressing trolley 6.Check the expiry dates and intactness of the equipment Application of nursing process in wound management  Implementation Verify patient's identify again Prepare the patient ⚬ Positioning ￭ Depends on location and easy access of the wound ￭ Place incontinence sheet under the wound if necessary Prepare the environment ⚬ Ensure adequate space for the procedure ⚬ Provide privacy ⚬ Adjust bed to comfortable working height ⚬ Attach the waste disposal bag away from sterile field which is lower than the waist level ⚬ Prepare appropriate adhesive tape to secure the dressing  Implementation Prepare the sterile dressing set ⚬ Check intactness, dryness and expiry date of all sterile packages ⚬ Arrange equipment inside the set according to aseptic technique principle ⚬ Add antiseptic solution into container after checking the expiry date, opening date & time, any presence of precipitate ⚬ Open extra sterile items if needed ⚬ Use sterile dissecting forceps to fully soak the swabbing gauzes with the prescribed solution ⚬ Squeeze the soaked swabbing gauzes which should be moist without dribbling  Implementation Remove the old dressing with gloves on or with forceps Note the characteristics of the exudate on old dressing Measure the wound size if appropriate Perform hand hygiene Using dissecting forceps to apply the sterile drape to establish an extended sterile field between the wound and the trolley Inform the patient that you will begin the procedure and provide reassurance Use one dissecting forceps for transferring swabbing gauzes while using another dissecting forceps for cleansing the wound Do not allow the tips of the two dissecting forceps touching each other  Implementation Clean the wound according to aseptic principle ⚬ From top to bottom/ proximal to distal ⚬ From inner to outer ⚬ From clean to dirty ⚬ One swab once Check the soiled swabbing gauze after each stroke and repeat strokes with new swabbing gauze untill the wound is thoroughly cleansed Clean the surrounding skin as far as the area to be covered by dressing materials Observe the wound, surrounding skin condition and patient’s response thoroughout the procedure  Implementation Pad dry the wound and surrounding skin with dry gauzes Apply an appropriate/ prescribed dressing to cover the wound without contaminating it The covering dressing should extend beyond the edge of the main wound by at least 2.5cm (1 inch) Secure the dressing appropriately with tape  After care Return patient to comfortable position Raise up bedside rail & lower bed to its lowest position Open the curtain if applicable Perform hand hygiene before leaving patient Discard used equipment appropriately Application of nursing process in wound management  Evaluation Assess the patient’s condition, especially the tolerance of procedure, pain level Assess the wound site for dressing intactness, appropriate tightness of securing the dressing  Documentation Document on progress sheet and/ or wound chart Including: ⚬ Date & time of dressing performed ⚬ Wound condition: ￭ location ￭ size ￭ discharge (color, consistency, amount, odor) on old dressing and during dressing ￭ wound bed colour ⚬ Antiseptic lotion used for dressing ⚬ Type of dressing applied ⚬ Patient’s reaction towards the procedure (e.g. any complain during procedure) Wound Irrigation  Wound Irrigation Steady flow of a solution across an open wound surface to achieve ⚬ wound hydration ⚬ remove deeper debris ⚬ assist with the visual examination Sterile technique is required May use syringe +/- angiocatheter Prepare a sterile container to collect return fluid Solution of choice: Normal Saline or other antiseptics Amount of pressure used in wound irrigation is a determining factor in successful wound cleansing High pressure pulsating lavage is more effective in reducint bacteria and removing necrotic tissue but also at risk of damaging granulation and epithelial tissue  Wound Irrigation According to Original Agency for Health Care Policy and Research guideline, safe and effective irrigation pressure as being 4-15 psi Pressure greater 15 psi may cause wound trauma A 35 ml syringe with a 18G/ 19G angiocatheter generate around 13 psi Irrigation can splash and spread bacteria to surround area & people. if necessary, nurse should wear face shield, mask & protective gown when performing wound irrigation Keep the syringe at least 1 inch from the wound Inject the stream solution into the wound with gently Position the patient so the solution runs from upper end of the wound downward  Wound Irrigation Work from cleanest to most contaminated part of the wound Watch for the return fluid, discontinue irrigation when return fluid is clear Clean the peri-wound area with normal saline, pad dry the wound and surrounding skin Do not irrigate wound with tunnel to prevent complications caused by incomplete removal of fluid in tunnel Wound packing  Wound Packing Indication: ⚬ For cavity wound or wound with a sinus, tunnel and/or undermining Purposes ⚬ Loosely fill dead space ⚬ Promote growth of granulation tissue to prevent premature closure ⚬ Facilitate the removal of exudate and debris  Principle For Wound Packing Moisten the packing material with a noncytotoxic solution such as Normal Saline Loosely pack the wound to fill the wound dead space with the packing material Do not let the packing material drag or touch the surrounding wound tissue before you put in into the wound Pack the wound until you reach the wound surface, but not higher than the wound surface to prevent excessive pressure exerted on the wound bed Only one piece of packing material will be used whenever possible to avoid risk of retained dressing/ packing materials All materials packed should be in its original size as far as possible Leave at least 2.5cm outside the wound for easy retrieval If tunneling is present, pack the tunneling area first  Wound Packing Check wound nurse’s / doctor prescription Always counter check the number of item removed from the wound against the documentation Inspect the wound cavity and the removed packing material to ensure no dressing material is retained unintentionally Clean the wound with the technique of simple wound dressing Select the appropriate size of packing material to avoid gauze cutting Soak packing material with Normal Saline or prescribed solution For packing the cavity, undermining or tunneling can use sterile dress applicators to help in packing Properly document the no. of item packed into the wound and solvent used to soaked the packing material Thank you for your attention References Berman, A. T., Frandsen, G., & Snyder, S. (2021). Kozier & Erb’s Fundamentals of Nursing, eBook, Global Edition. Pearson Education. Available at https://hkmu.primo.exlibrisgroup.com/permalink/852HKMU_INST/1c3n5ve/cdi_askewsholts_vlebooks_97812923598 09 Hospital Authority. (Apr 2019). Risk Alert. Retreived from https://www.ha.org.hk/haho/ho/psrm/EHARA53rd.pdf Hospital Authority. ( Oct 2019). Risk Alert. Retreived from https://www.ha.org.hk/haho/ho/psrm/THARA55th.pdf Hospital Authority Head Office. (2023). Basic nursing standars for patient care: Wound dressing. HospitalAuthority Head Office. (2022). Specialty nursing practice guideline: Wound packing. Gabriel, A. (2021). Wound Irrigation. Retrieved from https://emedicine.medscape.com/article/1895071- overview?form=fpf#a1 Taylor, C.R., Lynn, P., Bartlett, J. L. (2023). Fundamentals of nursing: The art and science of person-centred nursing care (10th ed.). Lippincott Williams & Wilkins. Nettina, S.M. (2019). Lippincott manual of nursing practice (11th ed.). Wolters Kluwer. Available at https://hkmu.primo.exlibrisgroup.com/permalink/852HKMU_INST/1b97e1t/alma990004269270108061