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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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• Assist the person and his or her family in planning details about
who needs to be notified after death and in organizing funeral arrangements or a will.
4.4. CONCLUDING DISCUSSION
The effective care of people who have an infectious condition or who
are immuno-suppressed depends upon the application of knowledge and
research to the practical setting, in order to ensure an environment which is
safe for patients/clients, visitors and staff. Infection control measures at
one level are perhaps so basic to our everyday practice that we may take
them for granted. This may mean that we put on protective clothing, wash
our hands and dispose of waste without really thinking about why we are
taking such precautions. The practices of source isolation and protective
isolation nursing forcefully make us aware of the risks of cross infection
and the need for agreed policies and procedures.
Maintaining an environment safe from cross infection requires agreed
standards of practice which apply across a broad range of disciplines,
workers and settings. Additional standards are required to guide specific
activities and areas of practice, for example in the operating theatre and in
the care of patient/clients who are particularly “at risk” or vulnerable.
Standards need to be based on a sound and easily understood rationale. Education and training can ensure that there is a common understanding of the requirements of staff to follow certain precautions and procedures. While each member of the health care team is responsible for his
or her own sphere of practice, it is important that personnel are identified
with responsibility for monitoring standards and ensuring that agreed protocols are followed.
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5. TISSUE VIABILITY NURSING: ASEPTIC TECHNIQUE,
WOUND HEALING AND WOUND MANAGEMENT
5.1. INTRODUCTION
Tissue viability nursing is a developing field of specialist interest in
nursing practice. It is concerned with the prevention of tissue damage
through pressure distortion, inflammation and infection and with
providing the optimum conditions for tissue repair and healing. In some
centers, specialist nurse posts have been created to develop and coordinate
policies, research and teaching in relation to tissue viability. In looking at
tissue viability in this section, we will explore developments in a number
of areas of nursing practice in this field. These are:
• Hand-washing.
• Aseptic technique.
• Understanding tissue damage and wound healing.
• Wound management.
• Changing wound dressings.
The learning objectives for this section are:
1. To analyze critically your own hand washing technique and
practice.
2. To increase your understanding of the principles of the aseptic
technique.
3. To develop your knowledge of tissue damage and wound healing.
4. To improve your knowledge of wound care theory and the princi-
ples of wound management.
5.2. HAND WASHING
Exercise. Hand washing practice.
Wherever, you are at the moment, stop reading this chapter and go
to the nearest sink. Wash your hands as you usually would when preparing to undertake an aseptic technique. Try not to change your usual
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practice in any way (only you will be judging your own practice in this
exercise).
Now try to recall each step that was involved. Write these down on
a piece of paper, so that you can refer to it later in the chapter.
Background information. Hand washing is the single most important procedure for preventing nosocomial (hospital-acquired) infection,
as hands have been shown to be an important route of transmission of infection. Studies have shown, however, that hand washing is rarely carried
out satisfactorily. The most important factor inhibiting hand washing is
“being too busy” or inaccessible sinks. Studies have shown that up to 89 %
of staff miss some part of the hand surface during hand washing. Figure 6
shows the areas of the hands most commonly missed following hand
washing.
Fig. 6. Areas most common missed following hand washing
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Exercise. Hand washing practice
Look carefully at the diagrams showing the areas of the hands most
commonly missed during hand washing. Now think back to your own hand
washing practice at the beginning of this section. Do you think that you
missed areas of your own hands? Or were you aware of the research findings and deliberately tried to pay attention to areas such as around the
back of the thumbs, between your fingers, and around your finger nails? Is
this your usual hand-washing practice or did you pay more attention because you were going to be asked to look critically at your hand-washing
technique?
If you think that your hand-washing technique could be improved
now that you have seen the illustrations and thought about your practice,
return to the sink and wash your hands again. This time try to “watch”
yourself washing your hands, pay careful attention to each area of your
hands (back and front).
If you are studying this pack as part of a group, you might want to
carry out the hand-washing experiment by rubbing a little vegetable dye
into your hands before washing them, then blindfold yourself while you
wash your hands as either as you would normally, or even as thoroughly
as you can. You may be surprised how hard it is to wash your hands thoroughly unless you concentrate on not missing any areas (even if you try
this exercise without the blindfold!)
Criteria for hand washing:
• Use soap.
• Use continuously running water.
• Position hands to avoid contaminating arms.
• Avoid splashing clothing or floor.
• Rub hands together vigorously.
• Use friction on all surfaces.
• Rinse hands thoroughly with hands held down to rinse.
• Dry hands thoroughly.
If they are available, using paper towels is the preferred method of
hand drying. They have been shown to be a quick, convenient and reliable
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method of drying hands, and preferable to roller towels or warm air dryers.
If paper towels are not available, it is suggested that when you are undertaking an aseptic technique a clean towel should be used each time. Hand
washing should be undertaken after patient/client contact and before an
aseptic technique is performed. Rings, bracelets, wrist watches and nail
varnish must be removed and sleeves rolled up before hand washing.
Exercise. Hand washing practice.
Look back at criteria for hand washing. How do they compare with
the way that you usually wash your hands when nursing? If you are not
sure, return to the sink and place the guidelines somewhere that you can
see them while washing your hands. Now wash your hands, closely following each of the steps listed.
Did you find that you were also thinking about the earlier exercise
and research findings on the areas we commonly miss during hand washing? How could you make use of this information about hand washing in
your practice setting? Will it really influence your future practice? How
can each of us ensure that the standard of our hand washing practice is
adequate?
Think about how you could use this information to teach nursing
students and other health care workers more effective hand washing
techniques?
Transient bacteria can be almost completely removed from the hands
by soap and water washing. Conversely, soap and water do not reduce the
number of resident bacteria by any significant amount. Resident skin flora,
such as Staphylococcus aureus, are removed most effectively by rubbing
the hands with a bactericidal alcoholic solution of chlorhexidine. Rinsing
the hands with alcoholic chlorhexidine 0,5 % has been found to remove
more resident skin flora than washing the hands with a chlorhexidine 4 %
detergent wash.
It is suggested that a preparation such as chlorhexidine 4 % detergent
wash is used for cleaning physically dirty or contaminated hands, while
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a bactericidal alcoholic hand rub should be used for disinfecting clean
hands, immediately before carrying out an aseptic technique. A nurse with
'socially clean' hands will not need to wash them during the aseptic procedure, but should use a bactericidal alcoholic hand rub, whenever disinfection is required, for example, after opening the outer wrappers of dressings. This will also remove the need to leave the patient/client during the
procedure to wash the hands at a basin, as it is unlikely that nurses' hands
will become soiled with blood or body fluids, as long as blood and body
fluid precautions are adopted at all times.
5.3. THE ASEPTIC TECHNIQUE
Definition. Aseptic technique is a method used to prevent contamination of wounds and other susceptible sites by organisms that could cause
infection. This can be achieved by ensuring that only sterile equipment and
fluids are used during invasive medical and nursing procedures.
Indications. An aseptic technique should be implemented during any
invasive procedure that bypasses the body's natural defenses, for example,
the skin and mucous membranes, or when handling equipment such as intravenous cannula and urinary catheters that have been used during these
procedures.
Background information. The literature shows that a significant
number of patients acquire some type of wound infection during their stay
in hospital, which is directly related to wound contamination at the time of
operation. Obviously, infection rates are likely to vary between different
countries and health care systems. Studies suggest that over half of wound
infections will be caused by aerobic Gram-negative bacteria, just over
a quarter by Gram-positive bacteria, and the remainder by anaerobic bacteria, fungi and viruses.
The diagnosis of infection relies on classic signs of inflammation,
such as local redness, swelling and pain. These local signs and symptoms
can precede a further sequence of events, which can be lymphangitis, lymphadenitis, bacteremia and septicemia which, if not promptly recognized
and treated, can result in death.
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The cost of infection is high, both to the patient/client and the health
care organization. The patient/client may be inconvenienced by a prolonged period of hospitalization, which can cause economic and social
hardships to the whole family. The hospital will have increased waiting
lists and increased hospital costs. It is essential when aseptic techniques
are used as a method of preventing infection, that these procedures are
sound in theory and are carried out correctly.
Principles of asepsis.
The risk of infection is increased if the patient/client is immunocompromised by:
• Age. Neonates and the elderly are more at risk due to their less ef-
ficient immune systems.
• Underlying disease — for example, patients/clients with severe
debilitating or malignant disease.
• Previous drug therapy, such as the use of immuno-suppressive or
broad-spectrum antimicrobial drugs.
• Patients undergoing surgery or instrumentation.
The following factors must be considered:
• Classic signs and symptoms of infection are often absent.
• Untreated infection may disseminate rapidly.
• Infections may be caused by non-pathogenic and unusual organisms.
• Some antibiotics are less effective in immuno-compromised pa-
tients/clients.
• Repeated infections may be caused by the same organism.
• Superimposed infection occurs frequently, requiring the highest
standards of care to prevent infection. This includes strict adherence to
aseptic techniques.
The most usual means for spread of infection include:
• Hands of the staff involved.
• Inanimate objects, such as instruments and clothes.
• Dust particles or droplet nuclei suspended in the atmosphere.
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Clinical nursing procedure guidelines: aseptic technique. Equipment:
• Clean trolley — reserved for aseptic procedures.
• Sterile dressing pack or an indented plastic tray, low-lining, non-
woven swabs and medical foam, disposable forceps, gloves, sterile field,
disposable bag.
• Fluids for cleaning and/or irrigation.
• Hypo-allergenic tape.
• Appropriate dressing.
• Appropriate hand hygiene preparation (for example, alcohol rub).
Any other material needed will be determined by the nature of the
dressing and any special features of this should be detailed in the patient/client's nursing care plan. The following clinical nursing procedure
guidelines reflect the principles of the aseptic technique in a hospital ward
setting and apply to all settings and all procedures which require an aseptic
technique.
Clinical procedure guidelines
Action
Rationale
1. Explain the procedure
to the patient/client
To obtain the patient/client's consent
and co-operation
2. Wash the trolley with liquid detergent
and water. Dry thoroughly with paper
towels or a clean linen towel
To provide a clean working surface.
The trolley should be washed every day
with detergent and water. It should not
need cleaning between dressings unless
a surface becomes physically
contaminated, since organisms cannot
survive on cold, smooth, dry surfaces.
The sterile field, usually made of thick
waxed paper, will not allow the passage
of organisms through it. Trolleys used
for aseptic procedures must not be used
for any other purpose
3. Place all the equipment required
for the procedure on the bottom shelf
of the clean dressing trolley
To maintain the top shelf as a clean
working surface
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Action
Rationale
3. Place all the equipment required
for the procedure on the bottom shelf
of the clean dressing trolley
To maintain the top shelf as a clean
working surface
4. Take the patient/client to the dressing
room (or screen the bed if this is not
possible). Air movement should be kept
to a minimum during the dressing
so adjacent windows should be closed
and the movement of people within
the area discouraged.
Position the patient/client comfortably
so that the area to be dealt with is easily
accessible without unduly exposing
the person
The spread of infection is most likely
to occur in a large, open ward. Ideally
dressings should all be performed
in a properly ventilated room. If dressings
have to be carried out at the patient's
bedside, ward cleaning should have
ceased at least 30 minutes before
and the curtains drawn at least 10 minutes
before a dressing is begun, in order
to allow dust and air-borne organisms
to settle before the sterile field
(and in the case of a dressing, the wound)
is exposed.
To maintain the patient/client's dignity
and comfort. To reduce to a minimum
the opportunities for air-borne
contamination, wounds should
be exposed for the shortest time possible
5. If the procedure is a dressing
and the wound is infected or producing
copious amounts of exudate, put on
a disposable plastic apron
There is evidence of transfer
of organisms from one room to another
on clothing. An impermeable apron (such
as a disposable plastic apron) offers
better protection than a cotton gown.
Where disposable aprons are not
available, washable clean plastic aprons
may be used or, if there is no alternative,
cotton gowns. Whichever is used, aprons
and gowns should be changed after each
dressing to reduce the risk of spreading
infection. In the ward environment, clean
wounds should be dressed before
contaminated wounds. Colostomies
and infected wounds should be dressed
last of all to minimize environmental contamination and infection
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Action
Rationale
6. Take the trolley to the dressing room
or patient/client's bedside, disturbing
the screens as little as possible
To minimize airborne contamination
7. Wash your hands with soap and water
(if available a bactericidal soap should
be used). Hands should be washed
according to Feldman's criteria
To reduce the risk of infection. Hands
have been shown to be an important route
of transmission of infection. Hand
washing is the single most important
procedure in preventing hospital
acquired infection
8. Check that the pack to be used
is sterile. It should be undamaged, intact
and dry. If autoclave tape is present,
check that it has changed colour. Open
the outer cover of the sterile pack
and slide the contents onto the top shelf
of the trolley
To ensure that only sterile products
are used. All instruments and materials
that come into contact with the wound
must be sterile if the risk
of contamination is to be reduced.
The central sterile supplies department
should normally provide all sterile
instruments. In the event of supplies
being short or in an emergency,
it is acceptable to disinfect a clean
instrument, such as a pair of scissors,
by immersing it completely in alcoholic
chlorhexidine 1 in 200 (70 %)
for five minutes
9. Do not allow the outer pack to touch
the surface of the top shelf
To avoid contamination of the clean
working surface
10. Open the sterile field using only
the comers of the paper
So that areas of potential contamination
are kept to a minimum
11. Check any other packs for sterility
and open, tipping their contents gently
onto the center of the sterile field
To prepare the equipment and in the case
of wound dressing, reduce the amount
of time that the wound is uncovered. This
reduces the risk of infection and a drop
in temperature of the wound
12. Wash hands, preferably with
a bactericidal alcohol rub
Hands may become contaminated
by handling outer packets, etc.
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