QUIZ 4 REVIEW

red color in wounds

healthy regeneration of tissue

yellow color in wounds

presence of purulent drainage and slough

black color in wounds

presence of eschar that hinders healing and requires removal

RYB color guide

* red: cover
* yellow: clean
* black: debride (remove necrotic(dead) tissue)

drainage (exudate)

a result of the healing process and accumulates during the inflammatory and proliferative phases of healing

For accurate measurement of drainage

weigh the dressing (1g = 1 mL drainage)

serous drainage

the portion of the blood (serum that is watery and clear or slightly yellow in appearance (fluid in blisters)

sanguineous drainage

contains serum and RBCs; thick and appears reddish.

* brighter drainage indicates active bleeding
* darker drainage indicates older bleeding/ drainage

serosanguineous drainage

contains both serum and blood; watery and looks pale and pink due to a mixture of red and clear fluid

purulent drainage

the result of infection; thick and contains WBCs, tissue debris, and bacteria

* may have foul odor and its color (yellow, tan, green, brown) reflects the type of organism present (green = pseudomonas aeruginosa infection)

purosanguineous

a mixed drainage of pus and blood (newly infected wound)

wound care nursing interventions

* provide adequate hydration and meet protein and calorie needs
* 2,500 mL/ day of fluids
* 1,500 kcal/ day
* albumin levels - if low (< 3.5 g/dL; more protein is needed; lack of protein delays wound healing
* administer analgesics (meds) & antimicrobials (topical, system) & monitor for effectiveness and pain management (reduced fever, increase in comfort, decreasing WBCs)
* wound cleansing and irrigation (least contaminated to most contaminated)

dehiscence

a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers

evisceration

a dehiscence that involved protrusion of visceral organs through a wound opening

hematoma

a local area of blood collection that appears as red or blue bruise

seroma

accumulation of serous fluid

deep tissue pressure injury

* result of intense and/or persistent pressure shearing force
* persistent nonblanchable, deep red maroon, or purple discoloration
* discoloration of non-intact or intact skin from damage following prolonged or intense pressure shear


* intact skin is nonblanchable (skin does not turn white when touched with a finger) with deep red, maroon, or purple discoloration; open wounds have a dark wound bed or blood blister (color changes vary depending on skin tone)
* pain and temperature changes can be detected earlier than color changes
* if subcutaneous or granulation tissue, or other structure (bone, fascia) are present, the wound should be restaged

stage 1, nonblanchable erythema of intact skin:

* intact skin with an area of persistent, nonblanchable redness that can feel warmer or cooler than the adjacent tissue
* the tissue is swollen and can have different texture than surrounding skin, with possible discomfort or altered sensation at the site
* with darker skin tones, the wound coloring differs from that of the surrounding area

stage 2, partial thickness skin loss with exposed dermis

* involves the epidermis and the dermis
* wound bed is viable with reddish-pinkish bed without slough, eschar, granulation tissue, or adipose tissue
* can appear as intact or ruptured blister
* can become infected, possibly with pain and scant drainage
* edema persists

stage 3, full thickness skin loss

* visible adipose tissue with possible granulation tissue and epibole (wound edges appear rolled under)
* some slough, eschar present
* no exposed muscle, tendons, ligaments, cartilage, or bones
* possible undermining or tunneling
* drainage and infection are common

stage 4, full thickness skin and tissue loss

* skin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or tendon exposed in the wound or easily palpable
* epibole, tunneling, undermining, deep pockets of infection, sinus tracts are common

unstageable, obscured, full-thickness and tissue loss

* no determination of stage because eschar or slough obscures the wound bed
* actual depth of injury is unknown unless slough and eschar removed, at which the time wound is restaged

device related-pressure injury

occur as a result of prolonged pressure from devices worn 

*  may be caused by medical devices, equipment, furniture, or everyday objects that are left in direct contact w skin
* medical devices that most frequently cause MDRPI (medical device–related pressure injury)include oxygen masks, oxygen tubing, urinary catheters, cervical collars, and compression stockings

mucosal membrane pressure injury

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 injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device

* mucosal tissues, including the lining of the respiratory tract, gastrointestinal tract, and genitourinary tract, are also at risk for developing pressure injuries from devices used for care
* respiratory equipment, endotracheal tubes, oxygen tubing, feeding tubes, and drainage tubes, urinary catheters


* cannot be staged, because mucosal tissue does not contain the same layers as the skin.

classifying pressure injuries in darkly pigmented skin

* skin temperature and level of moisture in the wound may be the first indicator of pressure injury
* edema, hardened skin, and localized pain, are also important factors to consider
* nurse should apply light pressure and then observe for an area that is darker than the surrounding skin
* skin can also appear taut, shiny, or indurated.

suspected deep tissue injury and stage 1 wound treatment

* relieve pressure
* encourage frequent turning and repositioning
* use pressure-relieving devices (an air-fluidized bed)
* implement pressure-reduction surfaces (air mattress, foam mattress)
* keep client dry, clean, well nourished and hydrated

stage 2 wound treatment

* maintain a moist healing environment (saline or occlusive dressing) apply hydrocolloid dressing
* promote natural healing while preventing the formation of scar tissue
* provide nutritional supplements
* administer analgesics

stage 3 wound treatment

* clean and/ or debride with the following
* prescribed dressing
* surgical intervention
* proteolytic enzymes
* provide nutritional supplements
* administer analgesics
* administer antimicrobials (topical and/or systemic)

stage 4 wound treatments

* clean and/or debride with the following
* prescribed dressing
* surgical intervention
* proteolytic enzymes
* preform nonadherent dressing changes every 12 hrs
* treatment can include skin grafts or specialized therapy (hyperbaric oxygen)
* provide nutritional supplements
* administer antimicrobials (topical and/or systemic)

unstageable wound treatment

* debride until staging is possible

when preforming wound care do not use

alcohol, dakin’s solution, acetic acid, povidone-iodine, hydrogen peroxide, or any other cytotoxic cleansers on a pressure injury wound

documenting pressure injuries

include the

* location
* stage
* size
* a description of the tissue
* the color of the wound bed
* the condition of the surrounding tissue
* the appearance of the wound edges
* the presence of undermining and tunneling
* and any foul odor present
* characteristics of any wound drainage observed
* reports of pain at the wound site

COCA

C: color

O: odor

C: consistency

A: amount (of drainage)

ideal dressing for maximum healing

a moist—not wet—wound bed is required

* Ideally, the dressing should pull excessive moisture from the wound, decreasing the probability of maceration of surrounding tissue, while leaving adequate moisture for the wound to heal.

clean vs sterile dressings

sterile:

* applied after surgery and are usually kept on the incision site for 24 to 48 hours; If dressing becomes saturated or loose, the dressing is changed using sterile technique

clean:

* after 48 hours, wounds are managed using clean technique during dressing changes, as the wound is considered to be colonized from the client’s environment
* used when dressing is required in home environment

wounds that are covered by dressings have been found to heal

faster than those not covered, and use of a dressing is associated with less scar formation

dressings are changed according to

provider’s prescription—most often daily, or every 2 days, or as needed due to excessive drainage.

open dressings

* gauze bandages
* assist with debridement process
* moistened w 0.9% sodium chloride (wet to dry)
* as it dries clings to tissue inside wound; removed tissue clung to gauze
* increased infection rates
* gauze fragments remain in wound after dressing
* rarely used

semi-open dressings

* three layers:
* bottom layer: comprises a layer of knit gauze that is more closely woven than traditional gauze; it is infused with therapeutic ointments
* middle layer:  contains padding and absorbent gauze
* top layer: adhesive
* do not control drainage
* risk for poor wound healing and breakdown of tissue adjacent to wound

films

* reduced ability to absorb moisture; self-adhesive transparent dressings are used for covering superficial wounds that have minimal exudate
* not recommended for excessive exudate; can leak and cause maceration & injury to epidermal layer
* allow moisture to evaporate while still maintaining a moist wound bed
* allow oxygen to enter the wound while decreasing the risk of micro-organism entrance into the wound
* promote wound healing and decrease infection
* can visualize wound w/o removal of dressing

hyrocolloid dressing

* used for small abrasions, superficial burns, pressure injuries, and post operative wounds
* occlude the wound
* maintain a moist wound bed
* have bacteriostatic properties
* stimulate growth of new granulation tissue
* can cause contact dermatitis and the foul-smelling, yellow, gelatinous film that develops as bacteria are trapped on the underside of the dressing

alginate dressings

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* recommended for moderate to highly exudative wounds.
* provide hemostasis
* have high absorptive abilities
* can remain in a wound for several days; less frequent dressing changes
* come in a variety of forms, including ribbons, pads, and beads, making them very versatile in terms of wound coverage and packing
* a secondary dressing is needed to cover the alginate, increasing the overall cost of wound management

hyrofiber dressings

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* moderate and highly exudative wounds
* provide high absorbency and can stay in the wound for several days
* draw less fluid from the wound edges; less maceration around the wound compared to alginate dressings

foams

* wounds with mild to moderate exudate; require more frequent dressing changes
* may produce a malodorous discharge.

polymeric membranes

* mildly exudative wounds
* stimulate the growth of new epithelium and do not stick to the wound bed; less trauma to the new granulation tissue

hydrogels

* used in dry wounds for debridement of necrotized tissue and eschar
* can provide moisture to or draw moisture away from the wound depending on the needs of the wound
* have a soothing effect and cause little trauma to the wound bed
* may require frequent dressing changes.

ostomies

area created in either large or small intestine

colostomy

part of the colon is used to form a stoma through the abdominal wall, allowing for the passage of body waste

* can be permanent or temporary
* stoma may be reversed by removing the colon from the abdominal wall and reconnecting it to the rest of the colon, so that bowel contents can continue to pass out of the body
* end in the colon

ileostomy

redirects the ileum through a surgically created opening (stoma or ostomy) in the abdominal wall to allow for the drainage of stool

* permanent ileostomies are created when the entire colon, including the rectum and anus, must be removed or bypassed
* can be reversed by removing the ileum from the abdominal wall and reattaching it to the colon so bowel contents can continue to pass through the colon (if temporary)
* end in the ileum

end stomas

result of colorectal cancer or some type of bowel disease

loop colostomies

help resolve a medical emergency and are temporary

* a loop of bowel is supported on the abdomen with a proximal stoma drainage stool and a distal stoma draining mucus
* usually constructed in the transverse colon

double-barrel colostomies

consist of two abdominal stomas: one proximal and one distal

* proximal stoma drains stool
* distal stomal leads to inactive intestine
* after injured area of intestine heals, colostomy often reversed by reattaching the two ends

paralytic ileus

an intestinal obstruction causes by reduced motility following bowel manipulation during surgery, electrolyte imbalance, wound infection, or by effects of medication

fecal occult blood (guaiac) test

* obtain a fecal sample using medical asepsis while wearing gloves


* collect stool specimens from serial guaiac testing 3 times from 3 different defecations
* some foods (red meat, citrus fruit, raw veggies) and meds can cause false positive results
* bleeding can be indication of cancer

diet after colostomy

Encouraging a client to eat foods high in fiber immediately after surgery is __***not***__ typically recommended as it may cause blockage or excessive gas. After a colostomy, diet generally needs to be slowly reintroduced and adjusted based on individual tolerance.

enema

instillation of a liquid solution through the anus to relive constipation or cleanse the bowel in preparation for diagnostic testing, procedure, or surgery

cleansing enema

instilled and retained for a few mins and then expelled by pt

retention enema

calls for pt to retain fluid for min of 15-30 mins depending on solution instilled before being expelled

enema solutions

contain bowel irritants that stimulate the bowl

* tap water (hypotonic) mineral oil
* 0.9% saline (isotonic)
* sodium phosphate (hypertonic) soultion

tap water enemas

cause a shift of fluids in the body and can cause water toxicity and circulatory overload; should never be used more than once in adults & never on infants and children

urinary diversions

created to reroute urine and can be temporary or permanent; for pts who have bladder cancer or injury

urinary incontinence

the inability to control urination resulting in its involuntary passage and can be caused by many factors.

urinary catheterization

pts may have a urinary catheter placed into the bladder to allow urine to drain

ureteral stent

primary purpose of the stent is to allow passage of urine when a ureter is blocked

* can happen due to; obstruction from a stone or mass, postoperative scar tissue, or inflammation and swelling from an infection
* temporary or longer period of time; change as needed

urinary incontinence in women

* pregnancy
* increased pressure and fluid vol increase need to urinate
* may cause urine leakage (urinary incontinence); usually reversible following birth
* pelvic organ prolapse or nerve damage
* loss of pelvic floor muscle (aging)

urinary incontinence in males

* enlarged prostate constricting flow of urine from bladder, can cause incomplete bladder emptying and urinary leaking

ureterostomy (ileal conduit)

section of the small intestine is removed from the GI tract, it is repositioned with one end attached to the ureters, and the other attached to the wall of the abdomen, where a stoma is created to allow urine to pass into a pouch attached to the abdominal wall

nephrostomy

an incontinent urinary diversion in which the surgeon attaches a tube from the renal pelvis via a stoma to the surface of the abdominal wall

cystomy

catheter is inserted directly into the bladder and attached to a drainage bag outside the client’s abdomen

j-pouch

internal pouch formed with the ileum; connects to the anus after removal of the rectum and colon; body waste collects in reservoir; instead of passing through colon and rectum it directly passes through the anus during a bowel movement

* usually created at the same time as ileostomy
* once healed will reverse ileostomy and connect ileum to J-pouch

kock pouch (continent ileal bladder conduit)

a continent urinary diversion in which the surgeon forms a reservoir from the ileum

* the pouch is emptied by clean straight catheterization every 2-3 hrs initially and every 5-6 hrs once pouch expands to capacity

neobladder

a new bladder created by the surgeon using the ileum that attaches to the ureters and urethra

* allows the client to maintain continence; learns to void by straining abdominal muscles

pain with urination

* suppression of the urge to urinate when there is pain in the urinary tract
* obstruction in the ureter leading to renal colic
* arthritis or painful joints causing immobility and leading to delayed urination

stress incontinence

coughing, sneezing, laughing, or physical activity that increases pressure on the bladder resulting in urine leakage

urge incontinence

a strong need or urge to urinate or defecate, but leakage occurs before getting to the toilet

reflex incontinence

urinary leakage as a result of nerve damage.

overflow incontinence

incomplete bladder emptying which results in the bladder overfilling when full resulting in urine leakage

nocturnal enuresis

nighttime bedwetting that is common in children but may occur in adults who have consumed too much alcohol or caffeine at night, or as a result of certain medications

functional incontinence

physical inability to reach the toilet in time

urinary retention

incomplete emptying of the bladder

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**symptoms include:**

* inability to urinate, pain, abdominal distention, urinary frequency, urinary hesitancy, weak or slow urinary stream, urinary leakage

UTIs

* causes by bacteria entering urinary tracts
* more common in women bc shorter urethra
* can lead to pyelonephritis (kidney infection)
* risk factors:
* sexual activity
* menopause
* urinary retention
* urinary obstruction
* frequent urinary catheter use
* diabetes
* urinary tract abnormalities
* symptoms:
* burning or painful urination and frequent urgency despite not being able to go

urinary urgency

a strong desire to urinate

interventions for incontinence

* lifestyle modifications including
* improving diet and exercising to prevent constipation
* reducing caffeine or alcohol intake
* avoiding medications that cause urinary incontinence, if possible
* quitting smoking
* pelvic floor exercises
* bladder retraining
* medications
* catheterization for overflow incontinence
* surgery.

skin breakdown (from chronic exposure to urine)

* keep the skin clean and dry
* assess for manifestations of breakdowns
* apply protective barrier creams
* implement a bladder-retraining program

peristalis

contractions that occur throughout the digestive system that move food along a pathway to be digested

meds that affect urine production (diuretics)

work to rid the body of excess fluid and salt, primarily to reduce blood pressure, but also to treat conditions such as heart failure and edema

* **thiazide diuretics**
* Chlorthalidone
* Hydrochlorothiazide
* Metolazone
* Indapamide
* **loop diuretics**
* Torsemide (Demadex)
* Furosemide (Lasix)
* Bumetanide
* **potassium-sparing diuretics**
* Amiloride
* Triamterene
* Spironolactone eplerenone

meds that affect stool production

* Antacids
* Anticholinergics and antispasmodics—medications used to treat muscle spasms
* Antiseizure medications
* Calcium channel blockers—medications used to primarily treat elevated blood pressure
* Diuretics—which increase urine production
* Iron supplements—used to treat certain forms of anemia
* Anti-Parkinson disease medications
* Narcotic pain medications—used to treat pain
* Antidepressants

diverticulosis

A condition in which small sacs or pouches form in the colon.

diverticulitis

An inflamed pouch or sac in the colon that is the result of stool becoming trapped.

ulcerative colitis

A chronic disease that causes inflammation and ulcerations of the large intestine or colon.

dysuria

pain or discomfort with urination often due to infection or injury

Uroflowmetry

Measures urine speed and volume 

Postvoid residual measurement 

Measures the amount of urine left in the bladder after voiding 

Cystometric test 

Measures bladder capacity, or the amount of fluid or pressure inside the bladder as it is filling, and its final capacity when the urge to urinate begins 

Leak point pressure measurement 

Measures bladder pressure when the bladder begins to leak 

Electromyography

Calculates electrical impulses of the nerves and muscles of the bladder and sphincters 

Video urodynamic test 

Takes pictures and video of the bladder while it is filling and emptying 

Cystoscopy

Uses an optical instrument to view the lining of the urethra and bladder 

Ureteroscopy

Uses an optical instrument to view the lining of the ureters and kidneys 

epidermis

The outer most layer of the skin, made of squamous epithelial cells, which provides a barrier against the external environment.