Wound/Ostomy Part 2

Question 1

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

Answer 1

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

Question 2

Describe the epidermis.

Answer 2

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.

Question 3

How thick is the epidermis?

Answer 3

Approx 20 cells thick

Question 4

Describe the dermis

Answer 4

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

Question 5

Describe subcutaneous tissue

Answer 5

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.

Question 6

Describe subcutaneous tissue

Answer 6

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.

Question 7

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

Answer 7

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

Question 8

hOW MANY STAGES OF PRESSURE INJIRIES ARE THERE?

Answer 8

4

Question 9

What is an unstageable pressure injury?

Answer 9

Full thickness tissue loss with slough/eschar

Question 10

What is a deep tissue injury

Answer 10

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

Question 11

What pressure injury is after stage 4?

Answer 11

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

Question 12

What are the healing stages?

Answer 12

stage 2, 3, and 4

Question 13

What is the Braden scale?

Answer 13

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.

Question 14

What is an IAD?

Answer 14

Incontinence associated dermatitis

Question 15

What should you say when documenting patient turns themselves?

Answer 15

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

Question 16

When do you use the hemodynamic instability guideline?

Answer 16

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

Question 17

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

Answer 17

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.

Question 18

Where does mepilex go?

Answer 18

The sacrum

Question 19

When do you change mepiliex?

Answer 19

Every 72 hours. Check under mepilex daily.

Question 20

When would you use pillows for positioning?

Answer 20

awake, alert, compliant, nonagitated, decreased mobility

Question 21

When would you use heel protector boots?

Answer 21

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

Question 22

When would you use a mepiliex heel dressing?

Answer 22

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

Question 23

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

Answer 23

false

Question 24

What is the skin’s natural PH?

Answer 24

6-7. Becomes inflamed at 9 or above

Question 25

How to manage skin fold

Answer 25

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.

Question 26

How to assess wound

Answer 26

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

Question 27

Describe the DIME model

Answer 27

Debridement, Inflammation, Moisture balance, Edge/Environment

Question 28

Define friable

Answer 28

Bleeding

Question 29

Define granulation

Answer 29

Flesh "filling" in

Question 30

Why do we keep wounds moist?

Answer 30

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

Question 31

Define neo-angiogenesis

Answer 31

new collateral circulation formation

Question 32

Name four abnormal edges of wounds

Answer 32

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

Question 33

What is an ostomate?

Answer 33

A person with an ostomy

Question 34

Ileostomy vs colostomies

Answer 34

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.

Question 35

Difference between end stoma vs loop stoma

Answer 35

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.

Question 36

When would you irrigate a colostomy?

Answer 36

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.

Question 37

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

Answer 37

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.

Question 38

Name four abnormal stomas

Answer 38

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

Question 39

What do you use to secure an ostomy?

Answer 39

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

Question 40

Describe how to change an ostomy site that has a pouch

Answer 40

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.