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Asepsis, Infection, Tissue Integrity

Mag Mag NURS 224 Inglês

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Asepsis
- remmeber use of PPE Hospital acquired infections
- Process keep microorganisms away, to not infect pt.
  - Aseptic technique
    - Practices to keep area or object free from microorganisms
      - Medical asepsis
        Clean technique
        HH, standard precautions, isolation
      - Surgical asepsis
        Sterile technique
        Patient prep pre-op, sterile procedures (wound dressing)
Chain of infection
- Shows transmission of infection from person to person, breaking any are of chain breaks infectious cycle.
  - Most common sites of health care associated infections
    - Wounds
    - Urinary tract
    - Respiratory tract
    - Bloodstream
    - Invasive procedures
Infection
- Microorganisims, viral, bacteril, fungal, parasitic/protozoa -Fungal infection sometimes d/t decreased immune sys from antibiotic tx -MRSA testign swab (armpit and nostrils) upon admission) -VRE(vancomycin resistan enterococcit, resistant to antibiotics)
- Invasion + multiplication of microorganisms in body tissue.
  - Clinically unapparent
    - OR cellular injury d/t
      - Competitive metabolism
      - Toxins
      - Intracellular replication
      - Antigen antibody response
  - Acute
  - Chronic
  - Localized or systemic
  - HAI
    - Infections acquired in hospitals
Sepsis
- Suspected or proven infection + systemic inflammation
  - Fever, tachycardia, tachypnea, elevated WBC, altered mental state, hyperglycemia w/o diabetes
  - Alterations
    - Vascular
      - Fluid shift in tissue, peripheral edema, hypovolemia, inflammation, immune response
        Peripheral vasoconstriction- send fluid to ventral circ to preserve vital organs, increase cardiac contractility
    - Renal
      - Vasodilation to rid waste product faster rate
    - NS
      - Altered mental state
    - Respiratory compensation
      - Increase in RR
    - VS
      - Fever, increased HR, RR, BP-compensation
        Late sepsis: Shallow breathing,low RR, increase in depth
Populations at risk
- SDOH
  - 1. Income social status
  - 2. Living condition
  - 3. Education
  - 4. Accessibility
  - 5. Nutrition
  - 6. Environment
  - Individual risk factors
    - 1. Compromised host: immunodeficiency, chronic illness
    - 2. Environmental: Living condition, access clean food and water, air quality
Assessment and Dx
- Urine output: 0.5-1.5ml/kg/hr 30mL/hr= normal
- CBC and differential
  - WBC: 4-11 X 10^9/L
    - fight infection
  - Neutrophils: 2-7 x 10^9/L
    - Granulocytes -Phagocytosis in first pahse of infection
  - Band neutrophils: <0.7 x 10^9/L
    - immature neutrophils recruted means body is not fighting welll enough, deteriorating
  - Monocytes
    - -Cellular mediated immune response, intervenes -Phagocytosis after transformation in macrophagocytosis
  - Basophils
    - Granulocytes Histamine release
  - Eosinophils
    - Granulocytes -Produces toxic proteins for certain parasites -Little bit of phagocytosis
- Culture and sensitivity test
  - To know what pt has to give more specific antibiotics, cause we usually start pt on broad spectrum antibiotic
  - Urine
  - Sputum
  - Blood
  - Wounds
  - Spinal fluid
  - PAN
    - URINE, BLOOD, STOOL
- Assess
  - Current + previous antibiotic therapy
  - Sings of infection: trauma, stress, dehydration, fever,
    - Sometimes we tx fever, when higher than 39-septic, if we tx it we may be masking fever, dont know if going up or down, when decompensating tx w/ antippyretics like tylenol
  - VS
- DI
  - identify where infection is. pneumonia, wound -visual inspection
  - X-Ray
  - CT scan
  - MRI
Shock
- Hypovolemic
  - Decrease in BV and CO. Lack in vascular compartment.
    - - Acute loss of 20% of BV -Cause: internal or external hemmorhage, severe dehydration, loss of GI fluid d/t vomiting or diarrhea, third space losses (ECF from vascular compartoment to interstitial space or compartment).
- Cardiogenic
  - Heart fails to pump enough blood to meet body demands
    - - Decrease in CO and cardiac index -Hypotension, SB<90mmHG -Hypoperfusion ot tissues and organs, indication of tissue hypoxia despite adequate intravascular volume -Causes: MI, myocardial contusion (bruise to heart muscle), sustained arrythmias (over 30 secs), cardiac sx, end stage condition of CAD or cardiomyopathy
- Septic
  - Severe sepsis / hypoperfusion, despite fluid resuscitation.
- Nursing care
  - Symptom management, correct cause of shock
Tissue integrity
- State of structurally intact and physiologically fx epithelial tissues (integument-skin and SC), and mucuos membranes.
  - Impaired tissue integrity
    - pain can impair tissue integrity
    - Damage to epithelial cells
      - Age related changes
        Reduced skin elasticity, collagen, moisture, poor perfusion d/t/ decreased elasticity thinning of muscle mass and tissues- more susceptible to tear
        Pressure Ulcer
         wound caused by unreleaved prolonged pressure to an area of the skin Ulcer can be mized
        Stage 1
        Intact, no open sores, red (hyperemia) w/o blanching after 30 minutes. Dark skinned- area darker than surrounding skin. Skin firmer or softer than surrounding skin. Measure at this stage.
        Stage 2
        Partial thickness, loss of dermis, wears away, Skin breaks open-forms ulcer, looks like abrasion. ,
        loss of epidermis a bit dermis
        Heal by regeneration
        1. Inflammatory response: redness, swelling,serous exudate. First 24 hrs. 2.Epithelial proliferation and migration: Starts at wound edges, epithelial cells start to migrate soon after wounding. Allowing quick resurfacing. Wounds kept moist resurface in 4 days, dry resurface in 6-7 days. Because epidermal cells migrate across moist surface only. In dry wound epidermal cells migrate first to moist are before migration can occur. 3. Re-establishment of epidermal layer: Cells slowly restablish normal thickness, appear as dry pink tissue.
        Stage 3
        Full thickness tissue loss. May see SC but not bone,muscle, tendon. Sinnus tunnel, measure w/ q-tip and ruler.
        loss of dermis and epidermis
        Heal by scar formation, deeper tissues don't regenerate.
        1. Inflammatory: Lasts about 3 days in full thickness wounds. Hemostasis to stop bleeding, form clot. Damaged tissue and mast cells secrete histamine- vasodilation surrounding capillaries, serum exudate, WBC. Cooling wont reduce swelling unless in a closed compartment (ankle, neck...). Neutrophils ingest bacteria and debris.Monocytes transform in macrophage for phagocytosis (bacteria, debris, dead skin cells).Prolonged if too little inflammation occurs. Too much decreases healing, too many cells competing for surrounding nutrients. 2.Proliferative (3-14 days): Angiogenesis, fill wound w/ granulation tissue, contracting wound (reduce area that needs healing), resurface wound w/ epithelization (epithelial cells migrate from wound edges to surface). Fibroblast- produce collagen, provide matrix for granulation, support re-epithelization. Impairment- d/t/ systemic factors (age, anemia, hypoproteinemia, low zinc). 3. Remodeling: Can last up to 2 years, collagen scar continues to gain strength. lighter color than normal skin d/t/ few melanocytes.
        Stage 4
        Loss of all tissue. Muscle, bone, tendon, visible and palpable, damage can happen to these.
        Stage X
        Can't see base of wound to know stage. Covered w, necrotic tissue or other tissues. Grey, green or black.
        Venous ulcers
        poor circulation, occur in lower extremities, poor blood return
        Superficial, irregular, lots of exudate d/t/ edema
        Venous insufficiency
        Weak vein walls, limited ROM of ankles decreases ability calf muscle to pump +
        Serum + RBC leak in surrounding tissues
        Brown hemosiderin staining of tissues and skin
        TX
        Hard to heal, pt may have tried diff tx like lanolin which may lead to contact dematitis
        Using simple natural products to clean, debride, moisten and cover
        avoid preservatives, chemicals and fragrances
        NS, autolytic debriding agents, preservative free hydrogesl, soft sillicone dressing
        Compression
        1. PT must have adequate blood flow for compression
        Diff types of compression based on pt goals and lifestyle
        Chronic
        Edema in tissues becomes firm
        Lower legs have wooden like appearance- lipodermatoclerosis
        Arterial (ischemic) ulcers
        d/t/ poor blood flow to lower extremities (poor arterial circ) - punched out appearance, deeper and smaller than venous ulcersLots have black eschar. Yellow fibrin, extremely painful. End up in a lot of amputations. Dry. no palpable pulse below ulcer.
        Feet, tips or toes or toe joints. Necrotic or pale wound beds
        Thin, shiny legs, taut skin, hairless, transluscent appearance
        Resistance to healing, goals is to provide comfort, maintenance wounds
        Not for debridement, poor blood flow decreases ability to heal
        TX
        Keep wound clean and dry
        Providone (Betadine): (10% in 1% solution)-0.25 providoe to 0.75 NS
        Soaked gauze in or on the wound, changed every day
        decreases bacteria, promote drying of wound -used in non healing wounds
        Diabetic ulcers
        Or neuropathic ulcer-Not painful, nerve damage -45% of lower extremity amputation occur in ppl w/ diabetes -One non traumatic limb amputation will results in 2nd limp amputation within 3yrs and death within 5 yrs (Canadian Fundamentals, Potter & Perry, 5th edition) Cliff like edges- deep, callous like 
        Hard to heal, d/t/ neuropathic changes, body prominence of the feet, often go unnoticed d/t/ decreased sensation
        decrease in ability to feel pain, temperature, decrease in sweating- cracks and fissures
        Assess w/ monfilament test
        Prevention w/ clos e inspection, palpation of feet
        each pt: propoer footwear, test water T,good foot care form certified specialist
        If can heal, debridement of necrotic tissue.
        Prophylactically tx w/ topical antimicrobial dressing
        Persistent pain at wound site, suspect osteomyletis (bone infection)
    - Phases of wound healing
      - 1. Hemostasis
        Clot formation, wound closes (in sx done w/ sutures or staples),24hrs
      - 2. Inflammation
        Inflammatory proces, mobilize mediators,pain, redness, swelling, 24-72hrs(may last up to 6 days)
      - 3. Proliferative
        Fibroblast degranulation,, kill bacteria and microphage to remove debris new tissue formation, angiogenesis, wound healing. 7-10 days after can last up to 21-25 days.
      - 4. Remodeling or maturation
        Healing done, scar starts to decrease, 21-2 months after.
      - Chronic wound
        Longer than 21 days, consider other factors affect healing, wound severity, SDOH
        Healing by intention
        The way surgical wounds heal -pressure ulcers, sx wounds w/ tissue loss
        First intention
        closed wound, sx wound sutured or stapled
        Straight edges, approximate well like cuts. Close wound ourselves w/ sutures or staples. Dry sterile dressing.
         Dressing is contraindicated of cyanoacrylate tissue adhesive (LiquiBand) used to close wound. -Granulation tissue not seen, minimal scaring 
        Second intention
        edges not approximated
        Edges not approximated, wound heals from bottom up, complex dressing used. Called granulation, when infection (abscess), pus or loss of tissue has occured.
        - Drainage tube or gauze packing is used to drain abscess -Packed with NS moistened sterile dressing cover with dry sterile dressing
        Wound drainage
        Made of blood components
        Plasma
        RBC
        WBC
        Platelets
        Surgical drains
        JP
        Pressure, as long as suction device is fully compressed
        Penrose
        Under dressing, maintained in place w/ clip, sudden stop of draining shows obstruction, Nurse should pull out slowly to prevent from slipping farther in wound w/ healing.
        Hemovac
        Pressure, as long as suction device is fully compressed
        Amount
        Color
        Oder
        Consistency
        Serous
        Serosanguineous
        Sanguinous
        Purulent
        Suspect infection, collect culture
        Thick, yellow, green, tan or brown
        Bright red , indicate active bleeding
        Red, pale, watery, mixture of clear and red fluid
        Clear watery plasma
        Third intention
        left open for several days then approximated -closure of wound is delayed until riskf of infection is resolved
        Wound left open to get drainage out and heal by secondary intention on purpouse. Deep wound not sutured early or break down and are resutured later-bring two apposing granulation surfaces.
        Deeper and wider scar packed post-op with moist gauze and covered with dry sterile dressing
        Factors impairing wound healing
        Surgical consideration:
        Surgical classification
        Clean surgery
        no signs of infection, not in major organs, ex: wrist sx
        Clean contaminated
        area exposed to elements (lungs, abdomen
        Contaminated
        Probably contaminated already, ex: gunshot wounds
        Dirty
        major trauma sc, no contact w/ hospital fro more than 4 hrs, could be gunshort wound depending on how longs
        Skin prep
        Site, duration, sx complexity
        Suture or foreign body
        Increases infection risk
        Pre existing local or systemic infection
        Use prophylactic antibiotics, mostly broad spectrum
        Haematoma
        Blood at wound
        Mechanical stress on wound
        Site- ex: buttocks, increased pressure
        Clip or shave increase risk of infection (microblading).
        Anesthetic considerations
        Patient individual risk factors
        Diabets
        Smoking
        Poor nutrition
        Alcoholism
        Chronic renal failure
        Jaundice
        Obesity
        Advanced age
        Poor physical condition
        Medication
        Previous radio or chemotherapy
        Tissue perfusion
        IV to maintain normal volemia
        Normovolemia, hypovolemia
        Perioperative body temperature
        Warmth increases circulation
        Concentration of inspired O2
        Analgesics
        Pain
        Analgesics
        Blood transfusion
        Hgb to carry O2
- Types of wounds
  - Acute
    - A wound that heals in orderly and timely manner. Restoration of anatomical and functional integrity
      - Cause: trauma, sx
        Easily cleaned, repaired, edges clean and intact
        implications for healing
  - Chronic
    - Fails to heal in orderly and timely manner to produce anatomical and functional integrity.
      - Cause: vascular compromise, chronic inflammation, repeated insults to wound
        Continued exposure to insults impedes healing
        implications for healing
  - Skin tears
    - -keep skin flap -remove foreigh bodies -use non adhering dressing -leae undisturbed as much as possible 
    - Risk factors
      - Aging: Thinning of epidermis,
      - Dehydration
      - Poor nutrition
      - Prolonged use of corticosteroids
      - Sensory and cognitive impairment
      - Tape or adhesive dressing can precipitate skin tears
        Use non adhering dressing
        -Telfa pads held in place w/ woven cotton wrapped bandage (Kling wrap) -Soft sillicone dressing
    - Cause: shear and friction
      - Partial or full thickness
        epidermis epidermis and dermis
Complications of wound healing
- Early complications
  - -all chronic wounds are considered contaminated w/ bacteria -infected wounds have larger amount of bacteria than contaminated -risk infection: necrotic tissue, contaminants near or in wound, reduced blood supplya nd local tissue defences
  - Internal hemmorhage (hematoma)
    - Localized collection of blood under tissues
      - Swelling, change in color,sensation, warmth, mass w/ bluish discoloration
        Dangerous near major artery or vein, pressure obstructs blood flow
        Distension or swelling, change in type and amount of drainage, signs of hypovolemic shock
        Data
        Inspection, hx, palpation, auscultation, DX
  - External Hemmorhage
    - Obvious look if pt is bleeding,
      - Observe all wounds closely esp 1st 24-48hrs, esp surgical wound, risk of bleeding is greatest
  - Superficial or Deep wound infection
    - 3-5 days to appear
    - Inhibits wound healing
      - S&S
        Fever
        Tenderness, pain at wound site
        Elevated WBC
        Inflammed edges
        Purulent drainage
        yellow, green, brown
        Linked to: Poor surgical technique, diabetes, wound contamination, obesity
        can't remove retention sutures as a student
  - Dehscence
    - Intervention: depending on when it happened, call fro help if new, VS, notify surgeon, reduce tension on wound, insert sterile gauze saline soaked over wound mostly b4 collagen formation, 3-11 days -pt at risk for poor wound healing = at risk fro dehiscence -increased risk in obese pt d/t constant strain on wound and poor healing ability of fat
    - Wound fails to heal, layers of skin separate, or too much pressure from sutures
      - Often happens when coughing, snizzing or sitting up
        Increase in serosanguinous drainage is a sign
        Prevention: pillow or blanket over wound when pt is coughing for support
        splints and support wound healing as coughing increases intrabdominal pressure
        Cause: infection, obesity, poor surgical technique
        TX
        Allow to heal by secondary intention
        SX
        Negative Pressure Therapy (VAC)
        Heal wound
        Stabilize wound
        Reduce exudate
        Reduce pain and discomfort
  - Evisceration
    - Total separation of wound layers, protrusion of visceral organs through wound opening
      - Emergency: Place NS soaked sterile gauze over opening contact surgeon
        Observe patient, keep patient NPO, prepare for sx
  - Fistulas
    - Abnormal passage b/w 2 organs or b/w organ and outside body.
      - D/t poor wound healing or disease complication like Chron's
        Trauma , infection, radiation, diseases like cancer, prevent tissue layers from forming properly and lead to fistula
        Chronic drainage of fluids through fistula predisposes pt fro skin breakdown
- Late complications
  - Abscess
  - Hypertrophic or Keloid
    - Raised d/t/ excessive collagen
Nursing Process
- Assessment
  - Identify risk factors for impaired skin integrity
  - S&S of impaired skin integrity or poor wound healing
  - Examine skin for actual impairment
  - To obtain baseline, continual assessment for critical thinking data
    - Skin assessment, risk assessment, Braden scale
  - Key Aspects of Clinical Mnagement
    - Primary Prevention
      - Patient repositioning
      - Assess nutritional status
        High caloric, high protein
      - Moisture
        Cream, barrier cream, hygiene
      - Toileting
    - Secondary prevention
      - Ex: Screening for cancer
      - Lab tests
    - Clinical Management
      - Pharmacotherapy
        Antibiotics (prevent infection), corticosteroids (dermatitis)
      - Treatment
        Wound care, phototherapy (warmth for circulation)
      - Nutrition, Fluid
        High protein, high caloric, vitamin C (collagen), H2O
      - Holistic
      - Invasive,SX
        Excision, debridement, grafting (flap sx, regraft muscle to a place that has had lots of tissue loss)
      - Dressings
        About moisture want to balance: dry-need moisture, too moisture need dry Choice based on assessment, pricing, pt and clinician preference
        Absorbent
        Manage exudate, super absorbers
        Non or Low adherent
        Film
        Protect extra moisure, transparent, clear: Opsite, Tegaderm
        Hydrogels
        Moisture: Gelli-perm, Intra site
        Alginate
        Absorb: Sorbsan, Kaltostat
        Hydrocolloids
        Moisture:Duoderm, Granufelx
        Foam
        Absorb, deep wound: Lyofoam, Allevyn
        Antimicrobials
        Wounds that look infected, expesnive: Silver, honey (add O2), iodine, PHMB
        Polyhexamethylene Biguanide
        Bioactive
        Growth factors, collagen stimulator, second intention healing, deep wound, expensive
        Medical grade leech therapy (reduces venous congestion, anticoagulant0 maggot therapy

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Descrição: NURS 224 Mapa Mental sobre Asepsis, Infection, Tissue Integrity, criado por Mag Mag em 18-02-2020.
Criado por: Mag Mag · fev 2020
Atualizado: 2 mar 2020
Visualizações: 7
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