Wound & Ostomy Flashcards

1
Q

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

A

calcium alginate dressing (pulls moisture out of wound)

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2
Q

What dressing do you use for necrotic wounds?

A

Silver (silfazorb/methylex AG)

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3
Q

What dressing do you use for infected wounds?

A

Notify team of infection, same as wet/necrotic wounds

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4
Q

How do you dress deep wounds?

A

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

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5
Q

Pressure injury is caused from

A

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

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6
Q

Shear vs. Friction injuries

A

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

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7
Q

One of the number one ways to prevent pressure injury

A

stage the body correctly

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8
Q

Stage one pressure injury looks like…

A

non-blanchable, over bony prominence

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9
Q

Stage two pressure injury look like…

A

Without slough open/ruptured serum filled OR serum filled bullas

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10
Q

Stage three pressure injury look like…

A

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

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11
Q

Stage four pressure injury look like…

A

You can see bone/muscle/tendon and tunneling

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12
Q

How do you measure a wound?

A

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

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13
Q

What do deep tissue injuries look like?

A

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

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14
Q

Mepilex dressinings are

A

5 layer foam dressings that reduce friction/shear

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15
Q

Mepilex dressings good for how long?

A

72 hours as long as they are not soiled

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16
Q

How often should you reposition a patient?

A

Every 2 hours

17
Q

Why keep the head of the bed under 30 degrees?

A

To maintain equal pressure

18
Q

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

A

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

19
Q

What is an unstageable injury (UI)?

A

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

20
Q

What is a deep tissue injury (DTI)?

A

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

21
Q

What is the Braden Scale?

A

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

22
Q

What is IAD?

A

Incontinence-associated dermatitis

23
Q

IAD v. Pressure Injury

A

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

24
Q

How do you heal a wound? DIME

A

Debridement
Inflammation/infection
Moisture Balance
Edge/environment

25
Q

How do you best avoid skin injury?

A

Clean
Moisturize
Protect
Skin fold management (InterDry)

26
Q

Why do you want to keep your wound moist?

A

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

27
Q

Ileostomy vs. Colostomy

A

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

28
Q

What is a urostomy?

A

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