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Nursing Essentials > Wound and Ostomy Care > Flashcards

Wound and Ostomy Care Flashcards

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1
Q

What can wounds be classified with

A

Cause, apperance, depth, length of healing

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2
Q

What could be some underlying causes of wounds

A

Diabetic or arterial ULCER, venous insuffficiency, PRESSURE injury, SURGERY

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3
Q

What is an arterial ulcer

A

Poor blood flow

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4
Q

What is venous insufficiency ulcer

A

Can’t get FLUID back SEEPS out leg

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5
Q

What can the apperance of wounds be

A

open or closed

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6
Q

What are some open wounds

A

Abrasion, puncture, surgical

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7
Q

What can be closed wound

A

Soft tissue, deep tissue, stage one pressure injury

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8
Q

What are the different depths of wounds

A

Superfical, partial thickness, full thickness

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9
Q

What is skin layers are superficial

A

Only epidermis

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10
Q

What skin layers are partical thickness

A

epidermis and dermis

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11
Q

What skin layers are full thickness

A

all the way to the sub q layers or muscle and bone

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12
Q

What are the lengths of wound healing

A

Acute, chronic

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13
Q

What is acute wound healing

A

Seeing progress with the healing process

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14
Q

What is chronic healthin

A

Fails to progess to healing in a timely manar

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15
Q

What is a clean wound

A

LOW risk for infection, SURGICAL incision

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16
Q

What is a clean-contaminated wound

A

Surgery involved a system that contained BACTERIA

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17
Q

What type of wound would happen after a tonsillectomy, bladder surgery, dental work, or work on mucous membranes

A

Clean contaminated wound

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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)

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19
Q

What type of wound would be a ruptured appendix or gunshot wound

A

contaminated wound

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20
Q

What is an infected wound

A

Shows SIGNS of infection

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21
Q

What type of wound would be a wound that has redness, warmth, and drainage

A

Infected wound

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22
Q

What is a colonized wound

A

Organisms are present on the surface but
NO signs of infection

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23
Q

What type of wounds are MRSA and chronic wounds

A

colonized wounds

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24
Q

What are the intentions with the would healing process

A

Primary, secondary, tertiary

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25
Q

What is a primary intention

A

Create insicion and close it

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26
Q

What is a secondary intetion

A

Create insicion and leave it open

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27
Q

What type of intention would you use for an infected wound, or large wound

A

Secondary

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28
Q

What is tertiary intention

A

Delay closing until its clean

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29
Q

What type of intentsion would you use for a gunshot wound to the GI tract

A

tertaiary

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30
Q

What are the three phases of wound healing

A

inflammatroy, proliferatice, maturation

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31
Q

How long does the inflammatory phase last

A

3 days

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32
Q

What happens during the inflammatory phase

A

CLOT formation, DILATED vessels, CLEANING

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33
Q

What happens at the end of the inflammatory phase

A

clean and ready to repair

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34
Q

What during the proliferative phase

A

New GRANULATION tissue, ANGIOGENESIS

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35
Q

How long does the proliferative stage last

A

several weeks but can be shortened with a surgically closed wound (primary)

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36
Q

What does angiogensis do

A

COLLAGEN synthesis, CONTRACTION, EPITHELIALIZATION

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37
Q

What is the maturation phase

A

COLLAGEN deposites scar tissue

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38
Q

How long can the maturation phase take

A

up to a year

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39
Q

What happens in the maturation phase

A

Scar tissue is formed

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40
Q

How strong is scra tissue compared to normal tissue

A

80%

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41
Q

Is scar tissue more at risk for forming a pressure injury

A

yes

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42
Q

What are the factors that affect wound healing

A

O2, diabetes, nutrition, age, infection

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43
Q

Why does O2 affect wound healing

A

Chronic perfusion issues lead to impaired healing

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44
Q

Why does diabetes affect wound healing

A

Microbascular changes, THICKENING of vessels and OCCULSION of blood flow leads to less O2 which leads to delayed healing

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45
Q

Why does nutrition affect wound healing

A

Protein, VIT C, A, zinc, copper

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46
Q

What does age effect wound healing

A

Decreased INFLAMMATORY response and COLLAGEN synthesis

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47
Q

What causes wrinkles

A

Decreased collagen

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48
Q

Why does infection affect owund healing

A

Prolonged inflammatory phase, prevent epithelialization

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49
Q

What is dehiscence

A

Partial or complete separation of tissue layers during healing process, organ are still inside

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50
Q

What is evisceration

A

Total separation of tissuues allowing visceral organs to protrude

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51
Q

Why do you need to teach your pts to splint while coughing

A

Can open wounds

52
Q

What should you do if evisceration happens

A

Cover with sterile normal saline moistened gauze and call provider

53
Q

What is a fistula

A

An abnormal connection or opening

54
Q

What are the two type of fistulas

A

Between the skin and an organ or an organ and an organ

55
Q

What can certain cancers, crohn’s disease, and radiation treatment cause

A

Fistulas

56
Q

What should you put of bare raw skin

A

zinc oxide barrier cream

57
Q

What are the different types of burns

A

Heat, electricity, radiation, chamical, cold, friction

58
Q

What type of burn has pain and blisters

A

Partial thickness

59
Q

Whay type of burn has just pain

A

superfical

60
Q

What type of burn has no pain

A

Full thickness

61
Q

If burns occur over large percentage of body, what is the patient at risk for

A

Fluid and electrolyte imbalance

62
Q

What is the only injury we stage

A

PRESSURE injuries

63
Q

What is best when it comes to pressure injuries

A

PREVENTION, turn q2hr, HOB <30 degrees, float HEELS, WEDGES, WAFFLES, CLEAN DRY skin

64
Q

What is the key for stage 1 pressure injuries

A

non blanchable skin

65
Q

What are you looking for in a wound assessment

A

LOCATION, SIZE, UNDERMINING, EXUDATE, EDGES, BED, RESPONSE

66
Q

What should you use when describing a wounds location

A

clear anatomical terms

67
Q

What should you use when describing the size of a wound

A

cm

68
Q

Which way is the length of a wound

A

heat to toe

69
Q

What is undermining

A

Cave like stricture

70
Q

What is tunneling

A

Little holes

71
Q

How do you measure depth in wounds

A

q-ti[s

72
Q

What should you note for the exudate of wounds

A

Color, consistency, odor, amount

73
Q

How can you check exudate

A

Old dressing

74
Q

What should you note about hte conditions of wound edges of wounds

A

maceration or infection

75
Q

What is maceration

A

Too wet, white, wet edges

76
Q

What do you want for a wound bed

A

Beefy red, shiny, moist

77
Q

What is slough

A

yellowy, debris

78
Q

What is eschar

A

Dead skin

79
Q

What should you do for the patients response to wounds

A

Pain managment, pre-medicating before changing wounds

80
Q

What is serous exudate

A

clear, watery

81
Q

What is sanguneous exudate

A

red, blood

82
Q

what is Serosanguinous exudate

A

clear and red fluid

83
Q

What is purulent exudate

A

yellow-green, infected, odor

84
Q

What should you do for wound cleansing and irrigation

A

Normal saline, remove contaminants, not too strong, clean EVERY change

85
Q

What are the 5 different types of debridement

A

Sharp, mechanical, enzymatic, aytolytic, biological

86
Q

What is sharp debridement

A

Scalpel, NO NURSE

87
Q

What is mechanical debridement

A

Wet-to-dry, DON’T DO

88
Q

What is enzymatic debridement

A

Topical agents (santyl), SLOW but effective

89
Q

What is autolytic debridement

A

Occlusive dressing, let’s the body do it’s thing, CONTARAINDICATED for INFECTED wounds

90
Q

What is biological debridemtn

A

Maggots

91
Q

What is the ideal wound healing enviroment

A

Moist and clean

92
Q

What can you use to manage exudate

A

Drains (JP, penrose)

93
Q

What is an advanced wound care tool

A

Negative pressure owund therapy (wound vac)

94
Q

What does a wound vac do

A

Remvoes excess FLUID, stabilizes wound EDGES, and STIMULATES granulation tissue, FAST

95
Q

What is an ostomy

A

A surgically created divertion to drain fecal material or urine

96
Q

What is a stoma

A

The outside organ of an ostomy

97
Q

What are some indications for an ostomy

A

Cancer, perforation, crohn’s disease, chronic ulcerative colitis, pressure injuries, paraplegia

98
Q

What will the consistency be of an ileostomy

A

Small intesion, watery

99
Q

What will the consistency be of a descending colostomy

A

Colon, formed

100
Q

Can ostomies be termporary or permanent

A

Yes

101
Q

What is an ileostomy

A

Small intension, frequent, liquid stool, RLQ

102
Q

What is a colostomsy

A

Large intension, more formed

103
Q

Should you assume what type of ostomy based on the location on the abdomin

A

No

104
Q

What are the indications for a urinary diversion

A

Bladder cancer, neurogenic bladder, trauma

105
Q

Are urinary diversions usally permentant

A

Yes

106
Q

What is a continent diversion

A

Pt has control over when they void

107
Q

What is an incontinent diversion

A

No control, has pouch

108
Q

What is an ileal conduit

A

Wear a pouch

109
Q

What is an orthotopic neobladder

A

continent diversion to urethra

110
Q

What is a continent cutaneous reservoir

A

They can put a catether in and then pee

111
Q

What should a healthy stoma look like

A

Turtleneck sweater, beefy red, moist, bleed easily, can see peristalsis

112
Q

What should the peristomal skin look like

A

Clean, dry, intact (CDI)

113
Q

What should you clean the peristomal skin with

A

water

114
Q

Why don’t you want to clean the peristomal skin with babt wipes or incontinence wipes

A

Won’t stick

115
Q

What is the goal of a pouch

A

PROTECT the skin, COLLECT drainage, control ODOR

116
Q

What are the two different type of pouches

A

One or two piece

117
Q

how often should you have to change a pouch

A

3-4 days

118
Q

What do you od to change a pouch

A

PREPARE supplies, have a FRIEND, CLEAN with WATER, DRY, APPLY new pouch, CLOSE clamp, DATE/TIME, DOCUMENT

119
Q

How much gap should you leave

A

Keep it off the skin

120
Q

How many times should the pouch be empties

A

5-6 times

121
Q

When should you empty it

A

before it’s full

122
Q

What should you do for fecal ostomies

A

burp them for get rid of gas

123
Q

What are some complications with stomas

A

painful SKIN around, CONVEX places, NECROTIC stoma

124
Q

What are some ways we can CARE for our pts with ostomies

A

No LIMITS, BATHING (on or off), INTAMACY (talk with partner), DIET changes (less gas), emergency SUPPLIES, EMOTIONAL support

125
Q

What are gasy foods

A

Broccoli, cussel sprouts, cabbage, onions

Nursing Essentials (9 decks)

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