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