Week 7: Wounds and Stomas Flashcards
Define:
Ostomy Appliances
Devices used to manage stomas, also known as ostomy bags. They can be either one-piece or two-piece systems and can be disposable or reusable.
What is…
Unexpected wounds often resulting from trauma, with potentially more irregular edges and higher infection risk.
Non-Surgical Wounds
Define:
Exudation
The leakage of plasma and blood components into the injured area, causing swelling.
What is…
A scar with no capillaries, which turns white as the healing process concludes, indicating a loss of vascularity.
Avascular Scar
What is…
Bright red fluid rich in red blood cells, indicating active bleeding.
Hemorrhagic Exudate
What is…
Wounds that affect the epidermis and part of the dermis
Partial Thickness Wounds
What is…
Wounds that are planned and intentional, usually resulting from invasive procedures like surgeries, with clean edges and minimal infection risk.
Surgical Wounds
Define:
Hemorrhagic Exudate
Bright red fluid rich in red blood cells, indicating active bleeding.
Define:
Malignant Wounds
Wounds that generally do not heal due to tissue changes that prevent closure, sometimes grouped with chronic wounds for management.
Define:
Hemostasis
The process of blood clotting to stop bleeding immediately after an injury.
Define:
Non-Touch Technique
A procedure where hands and non-sterile items do not come into contact with sterile surfaces or equipment, thus maintaining sterility.
Define:
Dirty/Infected Wounds
Traumatic wounds with dead tissue or intentional wounds with pre-existing infection, such as infected pressure injuries.
What is…
A surgical procedure that creates an opening to divert urine from the ureters (tubes from the kidneys) to the abdominal wall, typically positioned on the right side of the abdomen. It is used for conditions affecting the bladder or urinary tract.
Urostomy
What is…
The care and maintenance of an artificial opening created surgically on the abdomen to allow the discharge of bodily waste.
Stoma Management
Define:
Moist Wound Healing
A technique that involves keeping a wound environment moist to promote faster and more effective healing.
Define:
Pressure Ulcers
Wounds caused by prolonged pressure on the skin, typically in immobile patients, leading to decreased blood supply and tissue damage.
Define:
One-Piece Appliances
Ostomy appliances that combine the adhesive barrier and pouch into a single unit. Often preferred for colostomies, they are typically transparent, allowing easy monitoring of the stoma site.
Define:
Wound
A break or disruption in the normal integrity of the skin and underlying tissues, resulting from mechanical or non-surgical causes.
What is…
A set of practices aimed at preventing infection by maintaining a sterile environment during wound care.
Aseptic Technique
Define:
Collagen Remodeling
The process of reorganizing collagen fibers to increase the strength and stability of the healed tissue.
Define:
Superficial Wounds
Wounds confined to the epidermis
Define:
Autolytic Debridement
The body’s natural process of breaking down and removing dead tissue from a wound, which is facilitated by a moist wound environment.
What is…
Traumatic wounds with dead tissue or intentional wounds with pre-existing infection, such as infected pressure injuries.
Dirty/Infected Wounds
Define:
Inflammation
The response to injury involving vascular and cellular reactions, including swelling, elevated temperature, and pain, with white blood cells moving to the wound.
What is…
The final phase of wound healing starting around day 21 and lasting six to 12 months or longer, involving collagen remodeling and the development of a scar.
Maturation Phase
Define:
Mnemonic “TIME”
A tool used in wound management to remember key elements for assessing and treating wounds: Tissue, Infection, Moisture, Edge.
What is…
New tissue that forms to fill the wound space, consisting of fibroblasts and capillaries.
Granulation Tissue
Define:
Aseptic Non-Touch Technique (ANTT)
A method used to prevent infection during clinical procedures by minimizing contact with sterile areas and equipment, and by ensuring that microorganisms do not enter susceptible sites.
What is…
Presence of dead or devitalized tissue that prevents wound closure, often appearing yellow and sloughy or black and leathery.
Necrosis
Define:
Maceration
Overhydration of the wound leading to a change in pH, bacterial overgrowth, and skin erosion, which can cause the wound to deteriorate and increase in size.
Define:
Epithelialization
The process where new epithelial cells cover the surface of a wound during secondary intention healing, completing the healing process.
What is…
Wounds that generally do not heal due to tissue changes that prevent closure, sometimes grouped with chronic wounds for management.
Malignant Wounds
What is…
A type of wound healing where the wound cannot be closed immediately due to significant tissue loss. Healing occurs from the base upwards through granulation, leading to larger scars.
Secondary Intention Healing
Define:
Stomas
Openings created in the abdominal wall to allow the evacuation of fecal material or urine. They can be permanent or temporary, depending on the underlying medical condition.
What is…
Ostomy appliances consisting of a separate adhesive barrier and pouch. Commonly used for ileostomies, the barrier remains in place while the pouch can be changed frequently, facilitating easier management of the stoma.
Two-Piece Appliances
Define:
Acute Wounds
Wounds that heal in a predictable, timely manner, typically resulting from a recent injury.
Define:
Venous Ulcers
Chronic wounds caused by compromised venous return, often in elderly patients, with management involving bandages to control fluid leakage.
What is…
The process of forming new blood vessels, which is enhanced by maintaining a moist wound environment.
Angiogenesis
Define:
Moist Wound Healing
A method of wound care discovered by George Winter, where wounds are kept in a moist environment to promote faster healing compared to wounds that are left to dry. It reduces cell death, promotes the formation of new blood vessels, accelerates the natural breakdown of dead tissue, and leads to less pain and scarring.
Define:
Secondary Intention Healing
A type of wound healing where the wound cannot be closed immediately due to significant tissue loss. Healing occurs from the base upwards through granulation, leading to larger scars.
What is…
Healing that involves initially leaving the wound open and then closing it later, often used for contaminated wounds.
Tertiary Intention
What is…
Cells that secrete collagen to build new tissue during the proliferative phase.
Fibroblasts
What is…
The process of reorganizing collagen fibers to increase the strength and stability of the healed tissue.
Collagen Remodeling
What is…
The formation of new vascular tissue in the wound base during secondary intention healing, which fills the wound space and supports tissue repair.
Granulation
What is…
Intentional wounds created in sterile conditions, not involving entry into the respiratory, gastrointestinal (GI), or genitourinary (GU) tracts.
Clean Wounds
Define:
Clean Wounds
Intentional wounds created in sterile conditions, not involving entry into the respiratory, gastrointestinal (GI), or genitourinary (GU) tracts.
What is…
The process where new epithelial cells cover the surface of a wound during secondary intention healing, completing the healing process.
Epithelialization
Define:
Sterile Field
A designated area where all items are kept sterile to prevent infection, maintained by careful handling of sterile equipment and supplies.
Define:
Proliferative Phase
The phase starting around day two or three and lasting two to three weeks, where granulation tissue forms, fibroblasts secrete collagen, and capillaries grow to support healing.
What is…
The routine maintenance and management of a stoma, including cleaning, changing appliances, and monitoring for complications.
Stoma Care
What is…
Devices used to manage stomas, also known as ostomy bags. They can be either one-piece or two-piece systems and can be disposable or reusable.
Ostomy Appliances
Define:
Dry Dressings
Dressings used for uncomplicated wounds like post-operative incisions and abrasions to protect them from microorganisms. They can be applied using aseptic or clean techniques based on facility protocols.
Define:
Granulation
The formation of new vascular tissue in the wound base during secondary intention healing, which fills the wound space and supports tissue repair.
What is…
A method used to prevent infection during clinical procedures by minimizing contact with sterile areas and equipment, and by ensuring that microorganisms do not enter susceptible sites.
Aseptic Non-Touch Technique (ANTT)
What is…
A type of wound healing where the edges of a wound are brought together with sutures, staples, or sterile strips, typically resulting in a clean wound with a small scar.
Primary Intention Healing
Define:
Stoma Management
The care and maintenance of an artificial opening created surgically on the abdomen to allow the discharge of bodily waste.
What is…
Wounds that do not heal in the expected time frame and may require prolonged or advanced treatment.
Chronic Wounds
Define:
Stoma Care
The routine maintenance and management of a stoma, including cleaning, changing appliances, and monitoring for complications.
What is…
Thin, watery, yellow fluid with low protein levels, often seen in healing wounds.
Serous Exudate
What is…
Wounds caused by prolonged pressure on the skin, typically in immobile patients, leading to decreased blood supply and tissue damage.
Pressure Ulcers
What is…
A procedure where hands and non-sterile items do not come into contact with sterile surfaces or equipment, thus maintaining sterility.
Non-Touch Technique
What is…
A reduced immune response, either due to medication or poor health, affecting the inflammatory phase and overall wound repair.
Immunosuppression
Define:
Clean-Contaminated Wounds
Intentional wounds involving entry into the respiratory, GI, or GU tracts, which, despite being created in sterile conditions, are naturally exposed to bacteria.
What is…
A surgical procedure that creates an opening (stoma) from the colon to the abdominal wall, typically on the left side of the abdomen. It is used when part of the colon needs to be bypassed or removed due to conditions like bowel obstruction, trauma, or colorectal cancer.
Colostomy
Define:
Colostomy
A surgical procedure that creates an opening (stoma) from the colon to the abdominal wall, typically on the left side of the abdomen. It is used when part of the colon needs to be bypassed or removed due to conditions like bowel obstruction, trauma, or colorectal cancer.
Define:
Secondary Intention
Healing where the wound is left open to heal from the inside out, often resulting in more scarring.
Define:
Tertiary Intention Healing
A type of wound healing involving initially leaving the wound open for 3 to 5 days to allow for drainage of infection or reduction of swelling, followed by closure with sutures or staples once these issues resolve.
What is…
Open traumatic wounds or intentional wounds where sterile technique was compromised, leading to bacterial contamination.
Contaminated Wounds
Define:
Inflammatory Phase
The initial phase of wound healing, lasting about three to six days, characterized by hemostasis and inflammation to address injury.
What is…
The process of blood clotting to stop bleeding immediately after an injury.
Hemostasis
What is…
A technique that involves keeping a wound environment moist to promote faster and more effective healing.
Moist Wound Healing
Define:
Non-Surgical Wounds
Unexpected wounds often resulting from trauma, with potentially more irregular edges and higher infection risk.
What is…
The leakage of plasma and blood components into the injured area, causing swelling.
Exudation
What is…
Thick, yellow or green fluid containing pus, dead cells, and pathogens, indicating infection.
Purulent Exudate
Define:
Maturation Phase
The final phase of wound healing starting around day 21 and lasting six to 12 months or longer, involving collagen remodeling and the development of a scar.
What is…
Healing with minimal scarring, where edges of the wound are closely approximated.
Primary Intention
What is…
A tool used in wound management to remember key elements for assessing and treating wounds: Tissue, Infection, Moisture, Edge.
Mnemonic “TIME”
Define:
Chronic Wounds
Wounds that do not heal in the expected time frame and may require prolonged or advanced treatment.
What is…
Adherent fibrous material made up of proteins, fibrin, dead skin cells, and pathogens. It must be removed to promote healing.
Slough
What is…
Dressings used for uncomplicated wounds like post-operative incisions and abrasions to protect them from microorganisms. They can be applied using aseptic or clean techniques based on facility protocols.
Dry Dressings
What is…
The phase starting around day two or three and lasting two to three weeks, where granulation tissue forms, fibroblasts secrete collagen, and capillaries grow to support healing.
Proliferative Phase
What is…
A designated area where all items are kept sterile to prevent infection, maintained by careful handling of sterile equipment and supplies.
Sterile Field
Define:
Granulation Tissue
New tissue that forms to fill the wound space, consisting of fibroblasts and capillaries.
Define:
Serous Exudate
Thin, watery, yellow fluid with low protein levels, often seen in healing wounds.
What is…
Ostomy appliances that combine the adhesive barrier and pouch into a single unit. Often preferred for colostomies, they are typically transparent, allowing easy monitoring of the stoma site.
One-Piece Appliances
Define:
Fungating Breast Cancer Wounds
Wounds associated with advanced breast cancer that may not focus on healing but rather on managing appearance, pain, and comfort.
Define:
Angiogenesis
The process of forming new blood vessels, which is enhanced by maintaining a moist wound environment.
What is…
Healing where the wound is left open to heal from the inside out, often resulting in more scarring.
Secondary Intention
What is…
Swelling caused by excess fluid in the interstitial space, reducing blood flow and oxygen supply needed for wound repair.
Edema
What is…
Chronic wounds caused by compromised venous return, often in elderly patients, with management involving bandages to control fluid leakage.
Venous Ulcers
What is…
Intentional wounds involving entry into the respiratory, GI, or GU tracts, which, despite being created in sterile conditions, are naturally exposed to bacteria.
Clean-Contaminated Wounds
Define:
Fibroblasts
Cells that secrete collagen to build new tissue during the proliferative phase.
What is…
The initial phase of wound healing, lasting about three to six days, characterized by hemostasis and inflammation to address injury.
Inflammatory Phase
Define:
Immunosuppression
A reduced immune response, either due to medication or poor health, affecting the inflammatory phase and overall wound repair.
Define:
Contaminated Wounds
Open traumatic wounds or intentional wounds where sterile technique was compromised, leading to bacterial contamination.
What is…
Wounds that heal in a predictable, timely manner, typically resulting from a recent injury.
Acute Wounds
Define:
Tertiary Intention
Healing that involves initially leaving the wound open and then closing it later, often used for contaminated wounds.
What is…
A method of wound care discovered by George Winter, where wounds are kept in a moist environment to promote faster healing compared to wounds that are left to dry. It reduces cell death, promotes the formation of new blood vessels, accelerates the natural breakdown of dead tissue, and leads to less pain and scarring.
Moist Wound Healing
Define:
Primary Intention
Healing with minimal scarring, where edges of the wound are closely approximated.
What is…
The response to injury involving vascular and cellular reactions, including swelling, elevated temperature, and pain, with white blood cells moving to the wound.
Inflammation
What is…
The body’s natural process of breaking down and removing dead tissue from a wound, which is facilitated by a moist wound environment.
Autolytic Debridement
What is…
Openings created in the abdominal wall to allow the evacuation of fecal material or urine. They can be permanent or temporary, depending on the underlying medical condition.
Stomas
What is…
A break or disruption in the normal integrity of the skin and underlying tissues, resulting from mechanical or non-surgical causes.
Wound
What is…
Overhydration of the wound leading to a change in pH, bacterial overgrowth, and skin erosion, which can cause the wound to deteriorate and increase in size.
Maceration
What is…
Wounds associated with advanced breast cancer that may not focus on healing but rather on managing appearance, pain, and comfort.
Fungating Breast Cancer Wounds
Define:
Partial Thickness Wounds
Wounds that affect the epidermis and part of the dermis
Define:
Edema
Swelling caused by excess fluid in the interstitial space, reducing blood flow and oxygen supply needed for wound repair.
What is…
A type of wound healing involving initially leaving the wound open for 3 to 5 days to allow for drainage of infection or reduction of swelling, followed by closure with sutures or staples once these issues resolve.
Tertiary Intention Healing
Define:
Aseptic Technique
A set of practices aimed at preventing infection by maintaining a sterile environment during wound care.
What is…
Wounds that extend through the epidermis and dermis, potentially affecting deeper tissues.
Full Thickness Wounds
Define:
Full Thickness Wounds
Wounds that extend through the epidermis and dermis, potentially affecting deeper tissues.
Define:
Avascular Scar
A scar with no capillaries, which turns white as the healing process concludes, indicating a loss of vascularity.
What is…
A surgical procedure that creates an opening from the ileum (the last part of the small intestine) to the abdominal wall, usually on the right side of the abdomen. It is used for conditions that affect the lower parts of the digestive system, such as severe intractable incontinence or conditions requiring a cystectomy.
Ileostomy
Define:
Purulent Exudate
Thick, yellow or green fluid containing pus, dead cells, and pathogens, indicating infection.
Define:
Ileostomy
A surgical procedure that creates an opening from the ileum (the last part of the small intestine) to the abdominal wall, usually on the right side of the abdomen. It is used for conditions that affect the lower parts of the digestive system, such as severe intractable incontinence or conditions requiring a cystectomy.
Define:
Two-Piece Appliances
Ostomy appliances consisting of a separate adhesive barrier and pouch. Commonly used for ileostomies, the barrier remains in place while the pouch can be changed frequently, facilitating easier management of the stoma.
Define:
Slough
Adherent fibrous material made up of proteins, fibrin, dead skin cells, and pathogens. It must be removed to promote healing.
What is…
Wounds confined to the epidermis
Superficial Wounds
Define:
Primary Intention Healing
A type of wound healing where the edges of a wound are brought together with sutures, staples, or sterile strips, typically resulting in a clean wound with a small scar.
Define:
Surgical Wounds
Wounds that are planned and intentional, usually resulting from invasive procedures like surgeries, with clean edges and minimal infection risk.
Define:
Urostomy
A surgical procedure that creates an opening to divert urine from the ureters (tubes from the kidneys) to the abdominal wall, typically positioned on the right side of the abdomen. It is used for conditions affecting the bladder or urinary tract.
Define:
Necrosis
Presence of dead or devitalized tissue that prevents wound closure, often appearing yellow and sloughy or black and leathery.
What are the classifications of wounds?
Wounds are classified based on their depth, cause, and severity, including categories like abrasions, lacerations, punctures, and surgical wounds.
What are the phases of wound healing?
The phases are the inflammatory phase, the proliferative phase, and the maturation phase.
What occurs during the inflammatory phase of wound healing?
This phase involves the initial response to injury, including redness, heat, swelling, and pain, as the body works to prevent infection and start healing.
Describe the proliferative phase of wound healing.
In this phase, new tissue forms, including the development of granulation tissue and re-epithelialization, as the wound fills in and the edges start to close.
What happens during the maturation phase of wound healing?
The wound undergoes remodeling where the new tissue gains strength and elasticity, and the scar matures and becomes less prominent.
What are the three types of wound healing?
The three types are primary intention (healing with minimal scarring), secondary intention (healing by granulation), and tertiary intention (delayed closure).
Name some local factors that may affect wound healing.
Local factors include infection, tissue necrosis, and poor blood supply.
What are some systemic factors that can impact wound healing?
Systemic factors include diabetes, malnutrition, and chronic illnesses.
How do acute wounds differ from chronic wounds?
Acute wounds heal in a predictable time frame and typically without complications, whereas chronic wounds fail to progress through the normal phases of healing and persist longer.
What does the mnemonic “TIME” stand for in wound management?
“T” stands for Tissue management, “I” for Inflammation control, “M” for Moisture balance, and “E” for Edge advancement.
Why is moist wound healing important?
Moist wound healing promotes faster healing, reduces pain, and minimizes scarring by creating an optimal environment for cell migration and tissue repair.
What types of dressing products promote moist wound healing?
Dressing products that promote moist wound healing include hydrocolloids, hydrogels, and foam dressings.
Differentiate between an ileostomy, colostomy, and urostomy.
An ileostomy diverts the small intestine to the outside of the body, a colostomy diverts the large intestine, and a urostomy diverts urine from the urinary tract.
What is involved in the care of a stoma?
Stoma care involves regularly changing the appliance, cleaning the stoma site, and monitoring for any signs of complications or irritation.
What is the definition of a wound?
A wound is a break or disruption in the normal integrity of the skin and underlying tissues.
What are surgical wounds?
Surgical wounds are planned and intentional, resulting from invasive procedures like surgeries.
How do non-surgical wounds differ from surgical wounds?
Non-surgical wounds are unexpected and often result from trauma, whereas surgical wounds are planned and intentional.
What is the primary difference between acute and chronic wounds based on healing time?
Acute wounds generally heal within six weeks, while chronic wounds take longer than three months to heal.
What are partial thickness wounds?
Partial thickness wounds affect the entire epidermis but may leave parts of the dermis intact.
What are full thickness wounds?
Full thickness wounds involve the dermis and extend into subcutaneous tissue.
Give an example of an acute wound.
Examples of acute wounds include surgical wounds, burns, and gunshot wounds.
What distinguishes chronic wounds from acute wounds?
Chronic wounds fail to progress through the normal stages of wound healing and may not heal within three months.
What is a fungating breast cancer wound?
A fungating breast cancer wound is a type of chronic wound where the focus is on managing appearance, controlling pain, and maintaining patient comfort rather than healing.
What causes pressure ulcers?
Pressure ulcers result from prolonged pressure on areas of the body, often in immobile patients, leading to decreased blood supply and tissue damage.
What is the significance of wound classification for nurses and midwives?
Wound classification helps in effectively communicating about a patient’s progress and response to treatment.
How are wounds classified based on cleanliness?
Wounds can be classified as clean, clean-contaminated, contaminated, or dirty/infected based on the risk of bacterial contamination.
What characterizes a clean-contaminated wound?
A clean-contaminated wound is intentional, involving entry into the respiratory, gastrointestinal (GI), or genitourinary (GU) tracts, but the procedure is done under sterile conditions.
What is a contaminated wound?
A contaminated wound includes open traumatic wounds or intentional wounds where sterile technique was compromised.
What are dirty/infected wounds?
Dirty/infected wounds are traumatic wounds with dead tissue or intentional wounds with pre-existing infection.
What is a superficial wound?
A superficial wound is confined to the epidermis, such as a Stage 1 pressure injury.
What defines a partial thickness wound?
A partial thickness wound affects the epidermis and part of the dermis, like a Stage 2 pressure ulcer.
What is a full thickness wound?
A full thickness wound extends through the epidermis and dermis, potentially affecting subcutaneous tissue and deeper structures, such as a Stage 3 pressure ulcer or full-thickness burn.
How long does the inflammatory phase last?
The inflammatory phase lasts about three to six days.
What processes occur during the hemostasis phase of wound healing?
Hemostasis involves blood clotting to stop bleeding.
What happens during the inflammation phase?
During inflammation, blood vessels dilate, increasing capillary permeability to allow plasma and blood components to leak into the injured area, causing swelling, mild temperature elevation, and pain.
What role do white blood cells play in the inflammatory phase?
White blood cells move to the wound to ingest bacteria and cellular debris.
When does the proliferative phase begin, and how long does it last?
The proliferative phase begins around day two or three and lasts for about two to three weeks.
What occurs during the proliferative phase of wound healing?
Granulation tissue forms, wound closure begins, and new tissue is built to fill the wound space through fibroblasts secreting collagen and growing capillaries.
What is the duration of the maturation phase, and what happens during this phase?
The maturation phase begins around day 21 and can last for six to 12 months or longer, during which collagen remodeling increases the strength of the injured area, and the scar becomes avascular.
What percentage of its original strength does the tissue generally regain after the maturation phase?
The tissue generally regains about 70% of its original strength.
How do acute wounds progress through the phases of healing?
Acute wounds follow the normal wound healing process through the inflammatory, proliferative, and maturation phases.
What characterizes chronic wounds in terms of healing phases?
Chronic wounds get stuck in the inflammatory phase and cannot progress through the normal stages of wound healing.
What is the management goal for chronic wounds?
The goal is to restore normal wound healing physiology by promoting progression through the inflammatory, proliferative, and maturation phases.
How do malignant wounds differ from chronic wounds in terms of healing?
Malignant wounds generally do not heal and changes in tissue can prevent closure, whereas chronic wounds might still progress through healing phases with proper management.
Why is it important to educate patients on wound care before discharge?
Educating patients is crucial to prevent breakdown of the wound area and to manage the area properly to avoid further damage.
What is primary intention healing?
Primary intention healing occurs in surgical wounds with minimal tissue loss, where the wound edges can be easily brought together and closed with sutures, staples, or sterile strips, resulting in a clean wound with a small scar.
When is secondary intention healing used?
Secondary intention healing is used for wounds with significant tissue loss where the edges cannot be brought together, and healing occurs from the base upwards through granulation, leading to larger scars.
What distinguishes tertiary intention healing from primary and secondary intention healing?
Tertiary intention healing involves leaving the wound open for a period to allow drainage of infection or reduction of swelling before the wound edges are brought together for closure.
How does the healing process differ in primary intention compared to secondary intention?
In primary intention, the wound edges are approximated and closed with sutures or staples, leading to a small scar. In secondary intention, the wound heals from the base upwards through granulation, resulting in larger scars due to significant tissue loss.
Why might tertiary intention healing be chosen for a wound?
Tertiary intention healing is chosen to manage infection or swelling by keeping the wound open temporarily, allowing for proper drainage before closing the wound.
What type of wound healing is characterized by the formation of new vascular tissue?
Secondary intention healing is characterized by the formation of new vascular tissue as the wound heals from the base upwards through granulation.
Give an example of a situation where tertiary intention healing would be appropriate.
An example of tertiary intention healing is an open abdomen with gauze and dressing to manage drainage until inflammation subsides, after which the wound can be closed.
What is a key feature of wounds healed by primary intention?
Wounds healed by primary intention have clean, well-approximated edges with minimal tissue loss, resulting in a small scar.
What is a common result of wounds healed by secondary intention?
Wounds healed by secondary intention often result in larger scars due to significant tissue loss and healing through granulation and epithelialization.
How long is a wound typically left open during tertiary intention healing?
A wound is typically left open for 3 to 5 days during tertiary intention healing to allow for infection drainage or reduction of swelling before closure.
What effect does infection have on wound healing?
Infection can delay wound healing by causing the wound to remain stuck in the inflammatory phase, as bacteria produce toxins that interfere with healing and may cause cell death.
How does maceration impact wound healing?
Maceration, or overhydration of the wound, can change the pH of the skin, leading to bacterial overgrowth and skin erosion, which can cause the wound to break down and increase in size.
What is the impact of edema on wound healing?
Edema reduces blood flow to the area by increasing excess fluid in the interstitial space, which decreases the oxygen supply needed for cellular repair and division.
How does necrosis affect wound healing?
Necrotic tissue, which can appear yellow, sloughy, or black and leathery, prevents wound closure and impedes the healing process.
What are some local factors that can affect wound healing?
Local factors include infection, maceration, edema, necrosis, foreign bodies, pressure, and trauma to the wound site.
How does age affect wound healing?
Older adults often experience delayed wound healing due to chronic illnesses, age-related changes such as decreased mobility, and reduced blood supply to the wound.
Why is oxygenation and circulation important for wound healing?
Adequate blood flow and oxygen are crucial for wound healing as they supply the necessary nutrients and oxygen needed for tissue repair.
How does nutritional status impact wound healing?
Malnourished individuals or those lacking essential nutrients, such as zinc, vitamin A, and vitamin C, often experience delayed wound healing because these nutrients are vital for collagen formation and wound repair.
What role do medications play in wound healing?
Certain medications, such as chemotherapy, can delay wound healing by reducing cell proliferation and affecting the body’s ability to repair wounds.
How does immunosuppression affect wound healing?
Immunosuppression can impair the inflammatory phase, which is essential for cleaning up the wound and preparing it for repair, leading to delayed wound healing.
What effect does smoking have on wound healing?
Smoking reduces blood flow to the wound, impairs cell proliferation and regeneration, and negatively affects immune function, all of which can delay wound healing.
How do connective tissue disorders impact wound healing?
Connective tissue disorders can delay healing by affecting collagen synthesis and cell growth, which are essential for wound repair.
In what ways does obesity impact wound healing?
Obesity can negatively affect the immune system, impair nutrient absorption, and prolong the inflammatory phase of wound healing due to the increased presence of adipose tissue (fat).
What is the first step in wound management?
The first step is wound assessment, which involves considering both local and systemic factors affecting the patient and the wound.
What factors should be evaluated when assessing a wound?
Assess the patient’s established diagnosis, cause of the wound, overall health, and any underlying conditions that may impact wound healing.
What does the TIME framework stand for?
The TIME framework stands for Tissue, Infection or Inflammation, Moisture Balance, and Edge of the Wound.
What should you assess regarding ‘Tissue’ in the TIME framework?
Assess the type of tissue present, including necrotic tissue, slough, and granulation tissue. Necrotic and slough tissues need removal, while granulation tissue indicates healthy wound progress.
How can necrotic tissue affect wound healing?
Necrotic tissue, which appears black or dark gray, prevents wound closure and must be removed for healing to progress.
What are signs of infection or inflammation to look for in a wound?
Signs include redness, warmth, pain, and any unusual discharge such as greenish or foul-smelling exudate.
How does moisture balance impact wound healing?
A wound should be kept moist but not overly wet or dry. Proper moisture balance promotes healing by allowing fibroblasts to migrate and helps minimize scarring.
What is the significance of the edge of the wound?
Healthy surrounding tissue is necessary for proper wound closure. Poorly defined, calloused, or rolled edges can delay healing.
What are the three types of wound exudate?
Serous exudate (thin, watery, yellow), purulent exudate (thick, yellow or green, containing pus), and hemorrhagic exudate (bright red, indicating bleeding).
What does serous exudate indicate about a wound?
Serous exudate, being thin and yellow, typically indicates a healing wound with low levels of protein.
What does purulent exudate suggest?
Purulent exudate indicates infection, containing pus, dead cells, and pathogens.
How can hemorrhagic exudate be identified and what does it indicate?
Hemorrhagic exudate is bright red and contains many red blood cells, indicating active bleeding.
Why is aseptic technique important in wound management?
Aseptic technique is crucial to reduce the risk of surgical site infections (SSI) and other hospital-acquired infections.
What are the key concepts of aseptic technique to follow?
Follow the clean and dirty area concept, where one hand or instrument is designated as clean and the other as dirty, and the wound field concept, which maintains a sterile area around the wound.
How should you handle wound dressings to maintain asepsis?
Ensure hands or non-sterile equipment do not come into contact with the wound or sterile sites, following organizational procedures for wound care.
What does a multidisciplinary team involve in wound management?
A multidisciplinary team may include various specialists, such as orthotic experts for diabetic patients or those needing mobility aids, to address underlying conditions affecting wound healing.
What are some benefits of moist wound healing?
Reduces dehydration and cell death, promotes angiogenesis, accelerates re-epithelialization, enhances autolytic debridement, decreases pain, and improves cosmetic outcome.
How does moist wound healing affect the cosmetic outcome of the wound?
It improves the cosmetic outcome by resulting in a less severe scar.
What is the importance of selecting the right wound dressing product?
Different dressing products serve specific purposes, and choosing the correct one is crucial for effective wound healing.
Why is it important to consult a wound care specialist?
If a wound is not healing after several days with the same dressing, a specialist can help ensure the correct product is being used.
What is autolytic debridement?
The body’s natural process of breaking down dead tissue.
How does moist wound healing impact pain levels?
It decreases pain associated with wound healing.
What should you do if you’re unsure about which dressing product to use?
Consult a wound care specialist for guidance and make an informed choice.
Why are wound dressings becoming increasingly expensive?
New types are continually being developed, leading to higher costs and more options to choose from.
What is a colostomy?
A stoma created from the colon to the abdominal wall, often performed when part of the colon needs to be bypassed or removed.
Where is a colostomy typically located on the abdomen?
On the left side, usually in the lower region.
What is an ileostomy?
A stoma created from the ileum (the last part of the small intestine) to the abdominal wall.
Where is an ileostomy typically located on the abdomen?
On the right side, slightly higher than a colostomy.
What is a urostomy?
A stoma created to divert urine from the ureters to the abdominal wall.
Where is a urostomy typically positioned on the abdomen?
On the right side of the abdomen.
What are some common indications for a colostomy?
Bowel obstruction, trauma, ischemic bowel, perforated bowel, infection, inflammatory bowel disease (e.g., severe ulcerative colitis), or colorectal cancer.
What are some common indications for an urostomy?
Bladder cancer (requiring cystectomy), traumatic bladder injury, severe intractable incontinence, or conditions threatening bladder function.
How does the output from a colostomy typically compare to that from an ileostomy?
Colostomy output is thicker due to fluid reabsorption in the colon, while ileostomy output is more fluid and may be more transparent.
Why is the colostomy bag designed differently from the ileostomy bag?
To accommodate the differences in output consistency; colostomy bags are designed for thicker output, and ileostomy bags are designed for more liquid output.
What are the two types of ostomy appliances?
One-piece appliances and two-piece appliances.
What is a one-piece ostomy appliance?
A single unit that combines the adhesive barrier and the pouch, often preferred for colostomies.
What is a two-piece ostomy appliance?
A system consisting of a separate adhesive barrier and pouch, commonly used for ileostomies.
Why might a transparent ostomy appliance be preferred in acute settings?
It allows for easy observation of the stoma and its output.
What type of ostomy appliance is generally better suited for managing ileostomy output?
Two-piece appliances, as they handle more liquid and frequent output.
What type of ostomy appliance is usually sufficient for managing colostomy output?
One-piece appliances, as the output is generally thicker.
What is an important consideration when assessing the stoma color?
The stoma should be pink; if it appears pale or dark, it may indicate a problem.
What should the stoma feel like to the touch?
Warm
How should the stoma appear in terms of protrusion?
It should be protruding from the skin; a retracted stoma may indicate a problem.
What should you assess about the output from an ileostomy?
It should be fluid fecal matter.
What should you assess about the output from a colostomy?
It should be thick and consistent with colonic output.
What should you assess about the output from a urostomy?
It should resemble urine.
What should be the condition of the peristomal skin?
It should be intact and free from irritation.
Why is patient involvement important in stoma care?
Patients can provide valuable insights into the appearance, function, and output of their stoma, and engaging them in care is essential for effective management.
What should you do if you notice skin irritation around the stoma?
Consult a stoma nurse or specialist for additional support and advice.
How should you approach stoma care to support patients emotionally?
Be sensitive and involve patients in discussions about their stoma and how it impacts their lifestyle.
What is the primary purpose of classifying wounds?
A) To determine the cost of treatment
B) To assess the severity and guide appropriate treatment
C) To decide on the patient’s discharge date
D) To choose the hospital ward for the patient
B) To assess the severity and guide appropriate treatment
Which phase of wound healing is characterized by the formation of new tissue and blood vessels?
A) Inflammatory phase
B) Proliferative phase
C) Maturation phase
D) Hemostatic phase
B) Proliferative phase
During which phase of wound healing does the wound contract and strengthen?
A) Inflammatory phase
B) Proliferative phase
C) Maturation phase
D) Hemostatic phase
C) Maturation phase
What are the three types of wound healing?
A) Primary, secondary, and tertiary
B) Acute, chronic, and persistent
C) Clean, infected, and contaminated
D) Simple, complex, and complicated
A) Primary, secondary, and tertiary
Which type of wound healing involves direct closure of the wound edges with sutures or staples?
A) Primary intention
B) Secondary intention
C) Tertiary intention
D) Quaternary intention
A) Primary intention
What is an example of a systemic factor that may adversely affect wound healing?
A) Local infection
B) Excessive moisture
C) Diabetes mellitus
D) Mechanical stress
C) Diabetes mellitus
What does the T.I.M.E mnemonic stand for in wound assessment?
A) Timing, Infection, Moisture, Edges
B) Tissue, Inflammation, Moisture, Edge
C) Temperature, Infection, Moisture, Edges
D) Type, Infection, Management, Exudate
B) Tissue, Inflammation, Moisture, Edge
Which phase of wound healing is characterized by redness, heat, and swelling?
A) Inflammatory phase
B) Proliferative phase
C) Maturation phase
D) Hemostatic phase
A) Inflammatory phase
What is the key benefit of moist wound healing?
A) It speeds up wound infection
B) It reduces pain and scarring
C) It causes increased dehydration
D) It promotes wound drying
B) It reduces pain and scarring
Which dressing product is most appropriate for maintaining a moist wound environment?
A) Dry gauze
B) Hydrocolloid dressing
C) Transparent film dressing
D) Absorbent pad
B) Hydrocolloid dressing
What is a key difference between an ileostomy and a colostomy?
A) Ileostomy is located on the left side; colostomy is on the right
B) Ileostomy involves the small intestine; colostomy involves the colon
C) Ileostomy is a permanent stoma; colostomy is always temporary
D) Ileostomy has thicker output; colostomy has more liquid output
B) Ileostomy involves the small intestine; colostomy involves the colon
Which stoma is typically positioned on the right side of the abdomen?
A) Colostomy
B) Ileostomy
C) Urostomy
D) Gastrostomy
C) Urostomy
What is a common feature of a one-piece ostomy appliance?
A) Separate adhesive barrier and pouch
B) Combined adhesive barrier and pouch
C) Reusable design
D) Designed for high fluid output
B) Combined adhesive barrier and pouch
What should be assessed when examining the stoma color?
A) It should be yellow
B) It should be blue
C) It should be pink
D) It should be green
C) It should be pink
What is the primary function of a two-piece ostomy appliance?
A) It is used for managing ileostomy output
B) It combines the barrier and pouch into one unit
C) It is designed for less frequent changes
D) It is only used for temporary stomas
A) It is used for managing ileostomy output
How should you handle the tape when removing an old dressing?
A) Pull the tape towards yourself
B) Pull the tape away from the wound
C) Use short, gentle pulls to avoid stress on the wound
D) Tear the tape quickly to reduce discomfort
C) Use short, gentle pulls to avoid stress on the wound
What is a critical aspect of changing a stoma appliance?
A) The patient must remain completely still
B) The stoma should be retracted
C) The appliance should be placed without considering the patient’s comfort
D) The dressing should be applied without assessing the stoma output
A) The patient must remain completely still
How should the peristomal skin appear for proper stoma care?
A) Irritated and red
B) Intact and free from irritation
C) Dry and cracked
D) Moist and swollen
B) Intact and free from irritation
Which type of ostomy appliance is typically used for patients with a colostomy?
A) Two-piece appliance
B) One-piece appliance
C) Transparent appliance
D) Reusable appliance
B) One-piece appliance
What is an important consideration when assessing the wound output in a urostomy?
A) It should be solid and thick
B) It should resemble urine
C) It should be granular and thick
D) It should be opaque and heavy
B) It should resemble urine
