Wound & Ostomy Flashcards
What dressing do you use when treating a “wet” wound
calcium alginate dressing (pulls moisture out of wound)
What dressing do you use for necrotic wounds?
Silver (silfazorb/methylex AG)
What dressing do you use for infected wounds?
Notify team of infection, same as wet/necrotic wounds
How do you dress deep wounds?
wet to dry dressing, soaking gauze w/ norm saline. pack with antiseptic gauze
Pressure injury is caused from
ischemia (disrupted blood flow) to an area so that the tissue dies
Shear vs. Friction injuries
Shear: When skin is stuck to mattress and skin stays when pt moves. Friction: when sheets cause an abrasion on the skin
One of the number one ways to prevent pressure injury
stage the body correctly
Stage one pressure injury looks like…
non-blanchable, over bony prominence
Stage two pressure injury look like…
Without slough open/ruptured serum filled OR serum filled bullas
Stage three pressure injury look like…
No bone or muscle/tendon visible. Skin curls at edges of wound
Stage four pressure injury look like…
You can see bone/muscle/tendon and tunneling
How do you measure a wound?
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
What do deep tissue injuries look like?
Dark, bruise like with no blanching -. May also look like blood-filled blisters
Mepilex dressinings are
5 layer foam dressings that reduce friction/shear
Mepilex dressings good for how long?
72 hours as long as they are not soiled
How often should you reposition a patient?
Every 2 hours
Why keep the head of the bed under 30 degrees?
To maintain equal pressure
T/F: Depth of lesion determines stage of pressure injury?
False. All pressure injuries are full thickness. Stages reflect the structure involved in the injury.
What is an unstageable injury (UI)?
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
What is a deep tissue injury (DTI)?
Purple or maroon localized area of discolored, intact skin or blood-filled blister over bony-prominences. Epidermis is intact. Mushy or boggy to palpation
What is the Braden Scale?
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
What is IAD?
Incontinence-associated dermatitis
IAD v. Pressure Injury
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
How do you heal a wound? DIME
Debridement
Inflammation/infection
Moisture Balance
Edge/environment
How do you best avoid skin injury?
Clean
Moisturize
Protect
Skin fold management (InterDry)
Why do you want to keep your wound moist?
Wounds heal best in moist conditions- not too dry, not too wet
Promotes granulation tissue
Prevents eschar
Ileostomy vs. Colostomy
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
What is a urostomy?
Urostomy: ureter
Nursing Considerations:
High risk for dehydration
Higher risk for UTIs
Frequent emptying
Risk for leakage
No dietary restrictions
