Wound/Ostomy Part 2 Flashcards

1
Q

When would a insurance company pay a hospital for a pressure injury?

A

When the lesion is stage 3/4 and present on admission. Must be charted within 24 hours of admission.

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2
Q

Describe the epidermis.

A

5 layers of stratified epithelium. Basal cell layer migrates upward and eventually sloughs off of upper layer (stratum corneum/horny layer). Process takes 30 days. About 45 days for older adults.

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3
Q

How thick is the epidermis?

A

Approx 20 cells thick

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4
Q

Describe the dermis

A

Made up of collagen and elastin fibers. Strength, bulk, support, and elasticity. Sensory/motor nerves. Also contains sebaceous glands, sweat glands, hair follicles, capillaries, and lymphatics

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5
Q

Describe subcutaneous tissue

A

Everything below the dermis. A receptacle for the storage of fat (nutritional storage). Cushion, insulates, and supports other tissues. Vascular supply is between the dermis and subcutaneous tissue.

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6
Q

Describe subcutaneous tissue

A

Everything below the dermis. A receptacle for the storage of fat (nutritional storage). Cushion, insulates, and supports other tissues. Vascular supply is between the dermis and subcutaneous tissue.

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7
Q

What layer of the skin do stage 1 pressure injuries affect?

A

Full thickness. All pressure injuries are full thickness injury. DEPTH DOES NOT DETERMINE THE STAGE, BUT RATHER THE STRUCTURES INVOLVED IN THE WOUND BED.

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8
Q

hOW MANY STAGES OF PRESSURE INJIRIES ARE THERE?

A

4

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9
Q

What is an unstageable pressure injury?

A

Full thickness tissue loss with slough/eschar

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10
Q

What is a deep tissue injury

A

Purple skin sometimes filled with blood mushy boggy tissue. Epidermis is still intact.

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11
Q

What pressure injury is after stage 4?

A

Unstageable (US), and deep tissue injury (DTI)

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12
Q

What are the healing stages?

A

stage 2, 3, and 4

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13
Q

What is the Braden scale?

A

scale is 6-23. 6 is highest risk 23 is lowest risk. Test sensory impairment, moisture, mobility, activity, nutrition, friction. Individual sub-scores re more important than overall pressure injury risk.

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14
Q

What is an IAD?

A

Incontinence associated dermatitis

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15
Q

What should you say when documenting patient turns themselves?

A

Instead of “self turn” document R, L, B

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16
Q

When do you use the hemodynamic instability guideline?

A

When you need to run/reposition a patient but they are “too unstabe”

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17
Q

What is the best way to position a pt in bed?

A

TUrn pt on side at 30 degreee angle and position with wedge at back (above sacrum). Pillow between the legs. Top leg on bottom leg and float heels of pillows so they dont touch.

18
Q

Where does mepilex go?

A

The sacrum

19
Q

When do you change mepiliex?

A

Every 72 hours. Check under mepilex daily.

20
Q

When would you use pillows for positioning?

A

awake, alert, compliant, nonagitated, decreased mobility

21
Q

When would you use heel protector boots?

A

ICU, spinal cord injury, vascular disease, sedated/pralyzed, not ambulatory, not alert/oreinted, exisitng pressure injury

22
Q

When would you use a mepiliex heel dressing?

A

pt rejects heel boots, patient is ambulatory, agitated, exiiting pressure injury, vascular disease,

23
Q

T/F: “refuses to turn” documented covers you legally

A

false

24
Q

What is the skin’s natural PH?

A

6-7. Becomes inflamed at 9 or above

25
Q

How to manage skin fold

A

pat, no rubbing. cut fabric so that the length goes at least 2 inches past border of affected area. Have a single layer of fabric between fold.

26
Q

How to assess wound

A
  1. location 2. partial/full thickness 3. viable/non viable tissue 4. lengthxwidthxdepth 5. undermining/tunneling 6. exudate 7. odor 8. wound edge 9. periwound skin
27
Q

Describe the DIME model

A

Debridement, Inflammation, Moisture balance, Edge/Environment

28
Q

Define friable

A

Bleeding

29
Q

Define granulation

A

Flesh “filling” in

30
Q

Why do we keep wounds moist?

A

Promote granulation. Prevent eschar. Faster epithelialization. More exudate (wound releases fluid) the better.

31
Q

Define neo-angiogenesis

A

new collateral circulation formation

32
Q

Name four abnormal edges of wounds

A

Epibole (rolled edges), calloused edges, maceration, undermining

33
Q

What is an ostomate?

A

A person with an ostomy

34
Q

Ileostomy vs colostomies

A

Ileostomy have liquid/mushy outputs that are very acidic and hurtful to skin. Little smell. High volume of output. “small bowel eats for you, large bowel drinks for you”. High risk for malnutrition and dehydration. NEVER GIVE LAXATIVES. Empty when 1/3 full (a lot). Notify MD is output is greater than 1200ml/24hr

Colostomy large intestine. liquid to formed stool. Gas is common. Strong odor. Most common ostomy. Generally changed once/twice a day. Can become constipated and need to be irrigated. Limit foods that produce gas.

35
Q

Difference between end stoma vs loop stoma

A

Ends outside the abdomen. Look like a butt hole. Loop stoma goes out and dives back in. Has a slit in in so that contents escape.

36
Q

When would you irrigate a colostomy?

A

Can only be used in the descending/sigmoid colon. Where you hook a liter of fluid up to your ostomy so that peristalsis is stimulated and you poop out of your anus.

37
Q

What is a urostomy? (Ileal conduit/most common urostomy)

A

Ureters are hooked up to a piece of small intestine you remove from GI so you can form a stoma. When ureters empty it empties through stoma. Usually has a urine catheter coming out of it. High risk of dehydration. Increased UTI risk. Skin complications at site. No dietary restrictions.

38
Q

Name four abnormal stomas

A

Budded (little donut), retracted (labia), flush (vagina), prolapsed (penis)

39
Q

What do you use to secure an ostomy?

A

A skin barrier (wafer) sticker. Secures pouch to skin.

40
Q

Describe how to change an ostomy site that has a pouch

A

Pt lay flat. Removed old pouch. Cleanse stoma/surrounding areas w/ soft cloth and warm water. NO SOAP/BABY WIPES. Pull abdomen taunt to make flat as possible. Measure stoma w/ wafer box. Opening should be no larger that 1/8th inch of the stoma. Be prepared for things to come out when you’re cleaning. Seal wafer to skin by holding for 1 minute. Apply ouch to wafer. If it smells there’s a leak.

41
Q
A