Open Resources for Nursing (Open RN)
Learning Objectives
- Perform appropriate hand hygiene
- Use standard precautions
- Use category-specific, transmission-based precautions
- Maintain a sterile field and equipment
- Apply and safely remove sterile gloves and personal protective equipment
- Dispose of contaminated wastes appropriately
According to the Centers for Disease Control and Prevention (CDC), over 2 million patients in America contract a healthcare-associated infection, and 99,000 patients die from a healthcare-associated infection every year.[1] Healthcare-associated infections (HAIs) are unintended and often preventable infections caused by care received in a health care setting. Healthcare-associated infections can be prevented by consistently following standard precautions and transmission-based precautions outlined by the CDC (2020). Standard precautions are used when caring for all patients and include performing appropriate hand hygiene; wearing personal protective equipment when indicated; implementing category-specific transmission precautions; encouraging respiratory hygiene; and following environmental infection control measures, including handling of sharps, laundry, and hazardous waste. Additional infection control measures include the appropriate use of aseptic technique and sterile technique when performing nursing procedures to protect the patient from transmission of microorganisms.[2] Each of these strategies to keep patients and health care workers free of infection is discussed in further detail in this chapter.
- The Joint Commission. (n.d.). Hand hygiene. https://www.centerfortransforminghealthcare.org/improvement-topics/hand-hygiene/?_ga=2.185680553.1649963228.1601313691-322773533.1571518854 ↵
- Collins, A. S. (2008). Preventing health care-associated infections. In Hughes, R.G. (Ed.). Patient safety and quality: An evidence-based handbook for nurses. https://www.ncbi.nlm.nih.gov/books/NBK2683/ ↵
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
You are a nurse working in a long-term care facility. You have been assigned to care for Mr. Johns, a 74-year-old client recently diagnosed with a urinary tract infection, resulting in frequent incontinence. Mr. Johns suffered a cerebrovascular accident (stroke) six months ago and has difficulties ambulating and attending to his own needs because of weakness on his right side. Mr. Johns is alert and oriented to person, place, and time, but has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a wheelchair due to his difficulty with ambulation. He eats about 50% of his meals. While assessing Mr. Johns, you note that he is thin for his height, incontinent of foul-smelling urine, and has a red area of skin on his sacrum.
- What additional information, including lab work, would you like to gather to further assess Mr. Johns' potential for pressure injury development?
- What factors make him particularly vulnerable to the development of pressure injuries?
Test your knowledge using this NCLEX Next Generation-style bowtie question. You may reset and resubmit your answers to this question an unlimited number of times.[1]
Angiogenesis: The process of wound healing when new capillaries begin to develop within the wound 24 hours after injury to bring in more oxygen and nutrients for healing. (Chapter 10.3)
Approximated edges: The well-closed edges of a wound healing by primary intention. (Chapter 10.3)
Arterial insufficiency: A condition caused by lack of adequately oxygenated blood supply to specific tissues. (Chapter 10.2)
Braden Scale: A standardized assessment tool used to assess and document a client’s risk factors for developing pressure injuries. (Chapter 10.5)
Deep tissue pressure injuries: Persistent; non-blanchable; deep red, maroon, or purple discoloration of intact or nonintact skin revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. (Chapter 10.4)
Dehiscence: The separation of a surgical incision. (Chapter 10.2)
Dermis: The layer of skin underneath under the epidermis, containing hair follicles, sebaceous glands, blood vessels, endocrine sweat glands, and nerve endings. (Chapter 10.2)
Edema: Swelling. (Chapter 10.3)
Epidermis: The very thin, top layer of the skin that contains openings of the sweat gland ducts and the visible part of hair known as the hair shaft. (Chapter 10.2)
Epithelialization: The development of new epidermis and granulation tissue in a healing wound. (Chapter 10.3)
Erythema: Redness. (Chapter 10.3)
Eschar: Dark brown/black, dry, thick, and leathery dead tissue in wounds. (Chapter 10.4)
Excoriation: Redness and removal of the surface of the topmost layer of skin, often due to maceration or itching. (Chapter 10.2)
Exudate: Fluid that oozes from a wound. (Chapter 10.3)
Friction: The rubbing of skin against a hard object, such as the bed or the arm of a wheelchair. This rubbing causes heat that can remove the top layer of skin and often results in skin damage. (Chapter 10.4)
Granulation tissue: New connective tissue in a healing wound with new, fragile, thin-walled capillaries. (Chapter 10.3)
Hemostasis phase of wound healing: The first stage of wound healing when clotting factors are released to form clots to stop the bleeding. (Chapter 10.3)
Hypodermis: The bottom layer of skin, also referred to as the subcutaneous layer, consisting mainly of adipose tissue or fat, along with some blood vessels and nerve endings. Beneath this layer lies muscles, tendons, ligaments, and bones. (Chapter 10.2)
Impaired skin integrity: Altered epidermis and/or dermis. (Chapter 10.2)
Impaired tissue integrity: Damage to deeper layers of the skin or other integumentary structures. The NANDA-I definition of impaired tissue integrity is, “Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.” (Chapter 10.2)
Inflammatory phase of wound healing: The second stage of healing when vasodilation occurs to move white blood cells into the wound to start cleaning the wound bed. (Chapter 10.3)
Maceration: A condition that occurs when skin has been exposed to moisture for too long causing it to appear soggy, wrinkled, or whiter than usual. (Chapter 10.2)
Maturation phase of wound healing: The final stage of wound healing when collagen continues to be created to strengthen the wound and prevent it from reopening. (Chapter 10.3)
Necrosis: Tissue death. (Chapter 10.2)
Necrotic: Dead tissue that is black. (Chapter 10.2)
Nonblanchable erythema: Skin redness that does not turn white when pressed. (Chapter 10.4)
Pressure injuries: Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with shear. (Chapter 10.4)
Primary intention: A type of wound that is sutured, stapled, glued, or otherwise closed so the wound heals beneath the closure. (Chapter 10.3)
Proliferative phase of wound healing: The third stage of wound healing that begins a few days after injury and includes four processes: epithelialization, angiogenesis, collagen formation, and contraction. (Chapter 10.3)
Purulent: Drainage that is thick; opaque; tan, yellow, green, or brown in color. New purulent drainage should always be reported to the health care provider. (Chapter 10.6)
Sanguineous: Drainage from a wound that is fresh bleeding. (Chapter 10.6)
Secondary intention: A type of healing that occurs when the edges of a wound cannot be brought together, so the wound fills in from the bottom up by the production of granulation tissue. An example of a wound healing by secondary intention is a pressure ulcer. (Chapter 10.3)
Serosanguineous: Serous drainage with small amounts of blood present. (Chapter 10.6)
Serous: Drainage from a wound that is clear, thin, watery plasma. It’s normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage. (Chapter 10.6)
Shear: Damage that occurs when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue. (Chapter 10.4)
Slough: Inflammatory exudate in wounds that is usually light yellow, soft, and moist. (Chapter 10.4)
Stage 1 pressure injuries: Intact skin with a localized area of nonblanchable erythema where prolonged pressure has occurred. (Chapter 10.4)
Stage 2 pressure injuries: Partial-thickness loss of skin with exposed dermis. The wound bed is viable and may appear like an intact or ruptured blister. (Chapter 10.4)
Stage 3 pressure injuries: Full-thickness tissue loss in which fat is visible, but cartilage, tendon, ligament, muscle, and bone are not exposed. The depth of tissue damage varies by anatomical location. Undermining and tunneling may be present. If slough or eschar obscures the wound so that tissue loss cannot be assessed, the pressure injury is referred to as unstageable. (Chapter 10.4)
Stage 4 pressure injuries: Full-thickness tissue loss like Stage 3 pressure injuries but also have exposed cartilage, tendon, ligament, muscle, or bone. (Chapter 10.4)
Tertiary intention: The healing of a wound that has had to remain open or has been reopened, often due to severe infection or swelling. (Chapter 10.3)
Tunneling: Passageways underneath the surface of the skin that extend from a wound and can take twists and turns. (Chapter 10.4)
Undermining: A condition that occurs in wounds when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge. (Chapter 10.4)
Unstageable pressure injuries: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. (Chapter 10.4)
Venous insufficiency: A condition that occurs when the cardiovascular system cannot adequately return blood and fluid from the extremities to the heart. (Chapter 10.2)
