Wound & Ostomy

Question 1

What dressing do you use when treating a “wet” wound

Answer 1

calcium alginate dressing (pulls moisture out of wound)

Question 2

What dressing do you use for necrotic wounds?

Answer 2

Silver (silfazorb/methylex AG)

Question 3

What dressing do you use for infected wounds?

Answer 3

Notify team of infection, same as wet/necrotic wounds

Question 4

How do you dress deep wounds?

Answer 4

wet to dry dressing, soaking gauze w/ norm saline. pack with antiseptic gauze

Question 5

Pressure injury is caused from

Answer 5

ischemia (disrupted blood flow) to an area so that the tissue dies

Question 6

Shear vs. Friction injuries

Answer 6

Shear: When skin is stuck to mattress and skin stays when pt moves. Friction: when sheets cause an abrasion on the skin

Question 7

One of the number one ways to prevent pressure injury

Answer 7

stage the body correctly

Question 8

Stage one pressure injury looks like…

Answer 8

non-blanchable, over bony prominence

Question 9

Stage two pressure injury look like…

Answer 9

Without slough open/ruptured serum filled OR serum filled bullas

Question 10

Stage three pressure injury look like…

Answer 10

No bone or muscle/tendon visible. Skin curls at edges of wound

Question 11

Stage four pressure injury look like…

Answer 11

You can see bone/muscle/tendon and tunneling

Question 12

How do you measure a wound?

Answer 12

Measure first top-bottom then side-side. Use measuring tape to measure how long a tunnel is. Use a q-tip to go in and measure depth of tunnel

Question 13

What do deep tissue injuries look like?

Answer 13

Dark, bruise like with no blanching -. May also look like blood-filled blisters

Question 14

Mepilex dressinings are

Answer 14

5 layer foam dressings that reduce friction/shear

Question 15

Mepilex dressings good for how long?

Answer 15

72 hours as long as they are not soiled

Question 16

How often should you reposition a patient?

Answer 16

Every 2 hours

Question 17

Why keep the head of the bed under 30 degrees?

Answer 17

To maintain equal pressure

Question 18

T/F: Depth of lesion determines stage of pressure injury?

Answer 18

False. All pressure injuries are full thickness. Stages reflect the structure involved in the injury.

Question 19

What is an unstageable injury (UI)?

Answer 19

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown_ and/or eschar (tan, brown, or black) in the wound bed

Question 20

What is a deep tissue injury (DTI)?

Answer 20

Purple or maroon localized area of discolored, intact skin or blood-filled blister over bony-prominences. Epidermis is intact. Mushy or boggy to palpation

Question 21

What is the Braden Scale?

Answer 21

The overall score is determined by the scoring of 6 sub-score categories:
Sensory impairment, moisture, mobility, activity, nutrition, and friction
Individual sub-scores are just as important, if not more, in identifying risk

Very High Risk: 9 or less
High Risk: 10-12
Moderate Risk: 13-14
Mild Risk: 15-18
No Risk: 19-23

Question 22

What is IAD?

Answer 22

Incontinence-associated dermatitis

Question 23

IAD v. Pressure Injury

Answer 23

Pressure injury:
Occurs from bottom up
IAD: Incontinence-associated dermatitis
Occurs from top down
Erythema is blanchable
Usually in skin folds
Wider distribution
Briefs/diapers increase risk

Question 24

How do you heal a wound? DIME

Answer 24

Debridement
Inflammation/infection
Moisture Balance
Edge/environment

Question 25

How do you best avoid skin injury?

Answer 25

Clean
Moisturize
Protect
Skin fold management (InterDry)

Question 26

Why do you want to keep your wound moist?

Answer 26

Wounds heal best in moist conditions- not too dry, not too wet
Promotes granulation tissue
Prevents eschar

Question 27

Ileostomy vs. Colostomy

Answer 27

Ileostomy- ileum (SI)
Nursing considerations:
High volume of liquid output
High risk for malnutrition and dehydration
Do NOT give stool softeners or laxatives
Risk for leakage
Many foods can cause blockage
Raw vegetables
Nuts
Seeds
Chew food well, slowly introduce high-fiber foods
Avoid stimulating peristalsis (juice, soda)
Notify MD if output is >1200 mL/24hr

Colostomy- colon (LI)
End stomas and loop stomas exist
Nursing Considerations:
Usually require less emptying
Usually can have a normal diet
May require irrigation in cases of constipation
Sometimes, laxatives and softeners may be prescribed

Question 28

What is a urostomy?

Answer 28

Urostomy: ureter
Nursing Considerations:
High risk for dehydration
Higher risk for UTIs
Frequent emptying
Risk for leakage
No dietary restrictions