Wound and Ostomy Care Flashcards
1
Q
What can wounds be classified with
A
Cause, apperance, depth, length of healing
2
Q
What could be some underlying causes of wounds
A
Diabetic or arterial ULCER, venous insuffficiency, PRESSURE injury, SURGERY
3
Q
What is an arterial ulcer
A
Poor blood flow
4
Q
What is venous insufficiency ulcer
A
Can’t get FLUID back SEEPS out leg
5
Q
What can the apperance of wounds be
A
open or closed
6
Q
What are some open wounds
A
Abrasion, puncture, surgical
7
Q
What can be closed wound
A
Soft tissue, deep tissue, stage one pressure injury
8
Q
What are the different depths of wounds
A
Superfical, partial thickness, full thickness
9
Q
What is skin layers are superficial
A
Only epidermis
10
Q
What skin layers are partical thickness
A
epidermis and dermis
11
Q
What skin layers are full thickness
A
all the way to the sub q layers or muscle and bone
12
Q
What are the lengths of wound healing
A
Acute, chronic
13
Q
What is acute wound healing
A
Seeing progress with the healing process
14
Q
What is chronic healthin
A
Fails to progess to healing in a timely manar
15
Q
What is a clean wound
A
LOW risk for infection, SURGICAL incision
16
Q
What is a clean-contaminated wound
A
Surgery involved a system that contained BACTERIA
17
Q
What type of wound would happen after a tonsillectomy, bladder surgery, dental work, or work on mucous membranes
A
Clean contaminated wound
18
Q
What is a contaminated wound
A
HIGH risk for infection due to break in STERILE technique or from certain types of TRAUMA (particles, dirt)
19
Q
What type of wound would be a ruptured appendix or gunshot wound
A
contaminated wound
20
Q
What is an infected wound
A
Shows SIGNS of infection
21
Q
What type of wound would be a wound that has redness, warmth, and drainage
A
Infected wound
22
Q
What is a colonized wound
A
Organisms are present on the surface but
NO signs of infection
23
Q
What type of wounds are MRSA and chronic wounds
A
colonized wounds
24
Q
What are the intentions with the would healing process
A
Primary, secondary, tertiary
25
What is a primary intention
Create insicion and close it
26
What is a secondary intetion
Create insicion and leave it open
27
What type of intention would you use for an infected wound, or large wound
Secondary
28
What is tertiary intention
Delay closing until its clean
29
What type of intentsion would you use for a gunshot wound to the GI tract
tertaiary
30
What are the three phases of wound healing
inflammatroy, proliferatice, maturation
31
How long does the inflammatory phase last
3 days
32
What happens during the inflammatory phase
CLOT formation, DILATED vessels, CLEANING
33
What happens at the end of the inflammatory phase
clean and ready to repair
34
What during the proliferative phase
New GRANULATION tissue, ANGIOGENESIS
35
How long does the proliferative stage last
several weeks but can be shortened with a surgically closed wound (primary)
36
What does angiogensis do
COLLAGEN synthesis, CONTRACTION, EPITHELIALIZATION
37
What is the maturation phase
COLLAGEN deposites scar tissue
38
How long can the maturation phase take
up to a year
39
What happens in the maturation phase
Scar tissue is formed
40
How strong is scra tissue compared to normal tissue
80%
41
Is scar tissue more at risk for forming a pressure injury
yes
42
What are the factors that affect wound healing
O2, diabetes, nutrition, age, infection
43
Why does O2 affect wound healing
Chronic perfusion issues lead to impaired healing
44
Why does diabetes affect wound healing
Microbascular changes, THICKENING of vessels and OCCULSION of blood flow leads to less O2 which leads to delayed healing
45
Why does nutrition affect wound healing
Protein, VIT C, A, zinc, copper
46
What does age effect wound healing
Decreased INFLAMMATORY response and COLLAGEN synthesis
47
What causes wrinkles
Decreased collagen
48
Why does infection affect owund healing
Prolonged inflammatory phase, prevent epithelialization
49
What is dehiscence
Partial or complete separation of tissue layers during healing process, organ are still inside
50
What is evisceration
Total separation of tissuues allowing visceral organs to protrude
51
Why do you need to teach your pts to splint while coughing
Can open wounds
52
What should you do if evisceration happens
Cover with sterile normal saline moistened gauze and call provider
53
What is a fistula
An abnormal connection or opening
54
What are the two type of fistulas
Between the skin and an organ or an organ and an organ
55
What can certain cancers, crohn's disease, and radiation treatment cause
Fistulas
56
What should you put of bare raw skin
zinc oxide barrier cream
57
What are the different types of burns
Heat, electricity, radiation, chamical, cold, friction
58
What type of burn has pain and blisters
Partial thickness
59
Whay type of burn has just pain
superfical
60
What type of burn has no pain
Full thickness
61
If burns occur over large percentage of body, what is the patient at risk for
Fluid and electrolyte imbalance
62
What is the only injury we stage
PRESSURE injuries
63
What is best when it comes to pressure injuries
PREVENTION, turn q2hr, HOB <30 degrees, float HEELS, WEDGES, WAFFLES, CLEAN DRY skin
64
What is the key for stage 1 pressure injuries
non blanchable skin
65
What are you looking for in a wound assessment
LOCATION, SIZE, UNDERMINING, EXUDATE, EDGES, BED, RESPONSE
66
What should you use when describing a wounds location
clear anatomical terms
67
What should you use when describing the size of a wound
cm
68
Which way is the length of a wound
heat to toe
69
What is undermining
Cave like stricture
70
What is tunneling
Little holes
71
How do you measure depth in wounds
q-ti[s
72
What should you note for the exudate of wounds
Color, consistency, odor, amount
73
How can you check exudate
Old dressing
74
What should you note about hte conditions of wound edges of wounds
maceration or infection
75
What is maceration
Too wet, white, wet edges
76
What do you want for a wound bed
Beefy red, shiny, moist
77
What is slough
yellowy, debris
78
What is eschar
Dead skin
79
What should you do for the patients response to wounds
Pain managment, pre-medicating before changing wounds
80
What is serous exudate
clear, watery
81
What is sanguneous exudate
red, blood
82
what is Serosanguinous exudate
clear and red fluid
83
What is purulent exudate
yellow-green, infected, odor
84
What should you do for wound cleansing and irrigation
Normal saline, remove contaminants, not too strong, clean EVERY change
85
What are the 5 different types of debridement
Sharp, mechanical, enzymatic, aytolytic, biological
86
What is sharp debridement
Scalpel, NO NURSE
87
What is mechanical debridement
Wet-to-dry, DON'T DO
88
What is enzymatic debridement
Topical agents (santyl), SLOW but effective
89
What is autolytic debridement
Occlusive dressing, let's the body do it's thing, CONTARAINDICATED for INFECTED wounds
90
What is biological debridemtn
Maggots
91
What is the ideal wound healing enviroment
Moist and clean
92
What can you use to manage exudate
Drains (JP, penrose)
93
What is an advanced wound care tool
Negative pressure owund therapy (wound vac)
94
What does a wound vac do
Remvoes excess FLUID, stabilizes wound EDGES, and STIMULATES granulation tissue, FAST
95
What is an ostomy
A surgically created divertion to drain fecal material or urine
96
What is a stoma
The outside organ of an ostomy
97
What are some indications for an ostomy
Cancer, perforation, crohn's disease, chronic ulcerative colitis, pressure injuries, paraplegia
98
What will the consistency be of an ileostomy
Small intesion, watery
99
What will the consistency be of a descending colostomy
Colon, formed
100
Can ostomies be termporary or permanent
Yes
101
What is an ileostomy
Small intension, frequent, liquid stool, RLQ
102
What is a colostomsy
Large intension, more formed
103
Should you assume what type of ostomy based on the location on the abdomin
No
104
What are the indications for a urinary diversion
Bladder cancer, neurogenic bladder, trauma
105
Are urinary diversions usally permentant
Yes
106
What is a continent diversion
Pt has control over when they void
107
What is an incontinent diversion
No control, has pouch
108
What is an ileal conduit
Wear a pouch
109
What is an orthotopic neobladder
continent diversion to urethra
110
What is a continent cutaneous reservoir
They can put a catether in and then pee
111
What should a healthy stoma look like
Turtleneck sweater, beefy red, moist, bleed easily, can see peristalsis
112
What should the peristomal skin look like
Clean, dry, intact (CDI)
113
What should you clean the peristomal skin with
water
114
Why don't you want to clean the peristomal skin with babt wipes or incontinence wipes
Won't stick
115
What is the goal of a pouch
PROTECT the skin, COLLECT drainage, control ODOR
116
What are the two different type of pouches
One or two piece
117
how often should you have to change a pouch
3-4 days
118
What do you od to change a pouch
PREPARE supplies, have a FRIEND, CLEAN with WATER, DRY, APPLY new pouch, CLOSE clamp, DATE/TIME, DOCUMENT
119
How much gap should you leave
Keep it off the skin
120
How many times should the pouch be empties
5-6 times
121
When should you empty it
before it's full
122
What should you do for fecal ostomies
burp them for get rid of gas
123
What are some complications with stomas
painful SKIN around, CONVEX places, NECROTIC stoma
124
What are some ways we can CARE for our pts with ostomies
No LIMITS, BATHING (on or off), INTAMACY (talk with partner), DIET changes (less gas), emergency SUPPLIES, EMOTIONAL support
125
What are gasy foods
Broccoli, cussel sprouts, cabbage, onions
