Wound and Ostomy Care

What are the 5 wound classifications based on underlying cause?

Diabetic ulcer, arterial ulcer, venous insufficiency ulcer, pressure injury, and surgical wound.

What are examples of open wounds?

Abrasion, puncture wound, and incision.

What are examples of closed wounds?

Soft tissue injuries.

What is a superficial wound?

A wound involving the epidermis.

What is a partial-thickness wound?

A wound involving the dermis.

What is a full-thickness wound?

A wound extending into subcutaneous tissue.

What is an acute wound?

A wound that progresses rapidly through healing without complications.

What is an example of an acute wound?

A surgical incision.

What is a chronic wound?

A wound that fails to heal in a timely manner and remains open for an extended period.

What is a venous insufficiency ulcer associated with?

Fluid pooling in the lower extremities.

What 3 types of wound healing intentions are listed?

Primary, secondary, and tertiary intention.

What is primary intention healing?

Wound edges are approximated and closed using sutures, staples, or skin glue.

What is secondary intention healing?

Granulation tissue fills the wound from the bottom upward.

What is tertiary intention healing?

The wound is left open until infection or contamination resolves, then closed.

What are the 3 major phases of wound healing?

Hemostasis/inflammation, proliferation, and remodeling/maturation.

What happens during hemostasis?

Clotting factors activate to stop bleeding.

What happens during inflammation?

Histamine increases vasodilation and capillary permeability, producing an inflammatory response.

What happens during proliferation?

Granulation tissue forms, new blood supply develops, and re-epithelialization occurs.

What happens during remodeling/maturation?

Collagen strengthens, wound contraction occurs, and the scar develops.

What are the 4 main barriers to wound healing?

Impaired oxygenation/perfusion, poor nutrition, age, and infection.

Why is oxygenation important for wound healing?

Wound healing requires oxygen.

Why is perfusion important for wound healing?

Adequate blood flow is needed for healing.

What nutritional factors are important for wound healing?

Protein, calories, vitamins, and minerals.

How does age affect wound healing?

Older age can be associated with reduced collagen and increased vulnerability.

Why does infection interfere with wound healing?

Infection delays healing; debris or nonviable tissue can interfere with the wound bed.

What 7 components are included in wound assessment?

Location, size, undermining, tunneling, exudate, periwound skin, and wound bed description.

How should wound location be documented?

Using precise anatomical terminology.

What anatomical locations are given as wound examples?

Abdomen, greater trochanter, and ischium.

What units are used to measure wounds?

Centimeters (cm).

What measurements are included in wound size?

Length, width, and depth.

How is wound length measured?

At the longest point.

How is wound width measured?

At the widest point.

What is undermining?

Tissue destruction beneath the wound edges that creates a space under surrounding skin.

What is tunneling?

A channel or tract extending from the wound into surrounding tissue.

How can undermining and tunneling be described?

Using clock-face positions.

What clock positions are used in wound documentation?

12 o'clock toward the head and 6 o'clock toward the feet.

What is exudate?

Fluid or drainage from a wound.

What are the 4 types of wound exudate listed?

Serous, sanguineous, serosanguineous, and purulent.

What is serous exudate?

Clear, watery, plasma-like drainage.

What is sanguineous exudate?

Bright red bloody drainage.

What is serosanguineous exudate?

Pale pink, watery drainage containing clear fluid and blood.

What is purulent exudate?

Thick yellowish-green drainage that may have a foul odor.

Which exudate is clear and watery?

Serous.

Which exudate is bright red?

Sanguineous.

Which exudate is pale pink and watery?

Serosanguineous.

Which exudate is thick and yellowish-green?

Purulent.

What does periwound skin mean?

The skin surrounding the wound.

What is maceration?

Overly wet or moisture-damaged skin around a wound.

What wound bed findings are shown in the assessment practice?

Granulation tissue, slough, eschar, and maceration.

What does stage 1 pressure injury look like?

Intact skin with localized nonblanchable erythema.

What does stage 2 pressure injury involve?

Partial-thickness skin loss with exposed dermis.

What does stage 3 pressure injury involve?

Full-thickness skin loss; fat may be visible, but muscle, tendon, or bone is not exposed.

What does stage 4 pressure injury involve?

Full-thickness skin and tissue loss with deeper structures such as muscle, tendon, or bone exposed.

What is an unstageable pressure injury?

Full-thickness loss with the wound base obscured by slough or eschar.

What is a deep tissue pressure injury?

Localized discoloration of intact or nonintact skin indicating underlying tissue damage.

What is the purpose of wound cleansing?

Remove surface debris and contaminants.

What solution is listed for wound cleansing?

Normal saline.

How should a wound be irrigated?

With gentle force.

How often should wounds be cleansed?

During every dressing change, even when they look clean.

What is wound debridement?

Removal of nonviable tissue from a wound.

What are the 5 wound debridement methods?

Sharp, mechanical, enzymatic, autolytic, and biologic.

What is sharp debridement?

Removal of tissue with a scalpel or scissors.

Who performs sharp debridement?

A licensed provider.

What is mechanical debridement?

Debridement using wet-to-dry dressings.

What is enzymatic debridement?

Using topical agents to break down tissue; slow but effective.

What is autolytic debridement?

Self-debridement using an occlusive dressing.

What is biologic debridement?

Using medical maggots that secrete enzymes to liquefy necrotic tissue.

Which debridement method uses a scalpel or scissors?

Sharp.

Which debridement method uses wet-to-dry dressings?

Mechanical.

Which debridement method uses topical agents?

Enzymatic.

Which debridement method uses occlusive dressings?

Autolytic.

Which debridement method uses medical maggots?

Biologic.

What is the ideal wound environment for healing?

Clean and moist.

What determines the type of wound dressing and frequency of changes?

The wound's condition and moisture needs.

What is an important caution when using moist gauze?

Avoid allowing it to become an unintended wet-to-dry dressing.

What are 2 ways to manage wound exudate?

Absorbent dressings and drains.

What are the 3 drains listed in the lecture?

Penrose, bulb suction, and accordion drain.

What is a Penrose drain?

A drain that allows fluid to drain out from the wound.

What is a bulb suction device?

A drain that uses a collection bulb for drainage.

What is an accordion drain?

A drainage device that collects wound output.

Which drainage systems allow output measurement?

Closed collection drains such as bulb suction and accordion drains.

What are the 3 wound complications listed?

Dehiscence, evisceration, and infection.

What is wound dehiscence?

Separation of tissue layers during wound healing.

What is wound evisceration?

Separation of tissues with visceral organs protruding.

What is the difference between dehiscence and evisceration?

Dehiscence is wound separation; evisceration includes protruding internal organs.

What postoperative finding suggests wound dehiscence?

A popping sensation with sudden wetness in the dressing.

What is an ostomy?

A surgically created opening to divert and drain fecal material or urine.

What are the 2 general categories of ostomy diversion?

Bowel diversion and urinary diversion.

What are reasons for fecal diversion?

Cancer, perforation, Crohn's disease, chronic ulcerative colitis, sacral pressure wounds, and hemiplegia or paraplegia.

What conditions may cause bowel perforation requiring diversion?

Diverticulitis or trauma.

Can fecal diversions be temporary or permanent?

Yes, they can be temporary or permanent.

What determines fecal output consistency in an ostomy?

The location of the diversion along the GI tract.

What are the 2 types of fecal diversion listed?

Ileostomy and colostomy.

What is an ileostomy?

Diversion involving the small intestine that bypasses all of the large intestine.

What stool is expected with an ileostomy?

Frequent liquid stool.

What is a colostomy?

A diversion involving the large intestine.

What stool is expected with a colostomy?

Soft to solid stool.

Which ostomy produces frequent liquid stool?

Ileostomy.

Which ostomy produces soft to solid stool?

Colostomy.

What are reasons for urinary diversion?

Cancer, neurogenic bladder, and trauma.