wound and ostomy care

what are the three qualifications of wound classifications?

underlying cause, appearance, and depth

what are examples of an underlying cause of a wound?

diabetic ulcer, arterial ulcer, venous insufficiency ulcer, pressure injury, and surgical wound

what are examples of appearance of a wound?

open and closed

what is an open wound?

an abrasion, puncture wound, or incision

what is a closed wound?

soft tissue injuries, such as a hematoma, deep tissue pressure injury, or stage 1 pressure injury

what are the different depths of an injury?

superficial, partial thickness, and full thickness

what is an acute wound?

a wound that progresses rapidly through phases of healing without complications

what is a chronic wound?

a wound that fails to progress to healing in a timely manner and remains open for an extended time

what are the three wound healing options?

primary intention, secondary intention, and tertiary intention

what is primary intention wound healing?

an incision with a blood clot is closed with a suture, producing a fine scar

what are examples of a wound healed by primary intention?

staples, sutures, skin glue

what is secondary intention wound healing?

an irregular, large wound with a blood clot is filled in by granulation tissue, producing a large scar

what is tertiary intention wound healing?

• a contaminated wound that then granulates and closes with a suture when infection has left

• delayed primary intention

what are the phases of wound healing?

hemostasis/inflammation → proliferation → remodeling/maturation

what is the hemostasis/inflammation phase of wound healing?

• activating clotting factors to stop the bleeding

• histamine → vasodilation & capillary permeability → inflammatory response

what is the proliferation phase of wound healing?

granulation tissue, new blood supply, and re-epithelialization

what is the remodeling/modeling phase of wound healing?

collagen strengthens, causing contraction

what are four barriers to wound healing?

impaired oxygenation and/or perfusion, age, nutrition, and infection

why is impaired oxygenation and/or perfusion a barrier to wound healing?

not getting enough O2, platelets, collagen, etc., to tissue

why is age a barrier to wound healing?

healing processes work slower, there is higher comorbidity, less collagen, and thinner skin

why is nutrition a barrier to wound healing?

if you have poor protein, vitamin, and calorie intake, you don’t heal fast/well

what are the 7 ways to assess a wound?

location, size, undermining, tunneling, exudate, peri-wound skin, and wound bed description

how do you assess location of a wound?

clock format

how do you assess size of a wound?

• take the length, width, and depth

• measure in cm, not inches

what is undermining?

wound that goes under the skin

what is tunneling?

a hole in the wound that goes deeper than the majority of the wound

what are the four descriptors of drainage?

serous, sanguineous, serosanguineous, and purulent

what is the first step in wound cleansing?

use normal saline to remove surface debris and contaminants

what is the second step in wound cleansing?

irrigation with gentle force

when should a wound be cleaned?

during every dressing change, even if it looks clean

what are the five types of wound debridement?

sharp, mechanical, enzymatic, autolytic, and biologic

what is sharp wound debridement?

using a scalpel or scissors, limited to providers

what is mechanical wound debridement?

wet-to-dry dressings, discouraged

what is enzymatic wound debridement?

topical agents, slow but effective

what is autolytic wound debridement?

occlusive dressing, self-debridement; leaving wound in covered environment for body to do its thing

what is biologic wound debridement?

medical maggots secrete an enzyme to liquefy necrotic tissue

what does ideal wound healing look like?

clean and moist

what does the look of a wound determine?

the type of dressing and frequency of dressing changes

how do you manage exudate?

absorbant dressings or drains

what are three different types of drains used when managing exudate?

penrose, bulb-suction device, and accordion drain

what are three types of wound complications?

dehiscence, evisceration, and infection

what is dehiscence?

separation of tissue layers during healing; split open primary intention wound

what is evisceration?

separation of tissues with visceral organs protruding

what is a stoma?

surgically created protrusion to divert and drain fecal material or urine

why would someone have fecal diversions?

cancer, perforation, Chrons disease, chronic ulcerative colitis, sacral pressure injury/wounds, hemiplegia or paraplegia

in an ostomy, what does location along GI tract determine?

consistency of fecal matter

what are the types of fecal diversions?

ileostomy and colostomy

what is an ileostomy?

stoma of the small intestine, bypasses all of large intestine, and has frequent, liquid stool

what is a colostomy?

stoma of the large intestine, soft to solid stool

why would someone have urinary diversions?

cancer, neurogenic bladder, and trauma

what are the two descriptions of urinary diversions?

continent diversion and incontinent diversion

what are the three types of urinary diversions?

ileal conduit, contient cutaneous reservoir, and orthotopic neobladder

what is an ileal conduit urinary diversion?

part of the ileum becomes a false bladder; incontinent

what is a continent cutaneous reservoir urinary diversion?

part of the small intestine is made into a new bladder, urethra is still used

what is an orthotopic neobladder urinary diversion?

there is continent diversion to the urethra

what does a healthy stoma look like?

• looks like a turtleneck sweater

• beefy and moist

• may bleed easily, may see peristalsis

• no sphincter

what does healthy peristomal skin look like?

clean, dry, and intact

how do you clean peristomal skin?

with water and gauze/paper towel; no baby wipes or incontinence wipes

what is the purpose of an ostomy pouch?

protect the skin, collect output, and control odor

what are the two types of ostomy pouches?

two-piece pouching system and a one-piece pouching system

what is a two-piece pouching system?

• the skin barrier and pouch are two separate pieces connected by a plastic ring (flange)

• pouch can be removed and changed without removing skin barrier from body

what is a one-piece pouching system?

the skin barrier and the pouch are a single unit and must be removed together when changed

how often do you change the pouch system?

every 3-4 days

when do you empty an ostomy pouch?

when 1/3 to 1/2 full, be proactive!

what are examples of stoma complications

a prolapsed stoma, necrotic stoma, or recessed stoma

how do you care for a patient with an ostomy?

with professionalism, therapeutic communication, and providing emotional support