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A collection of questions and answers related to wound care, specifically geared towards preparing for the wound care rn exam. It covers various aspects of wound healing, including secondary intention, partial thickness repair, chronic wound healing, vitamin c's role in collagen formation, protein intake requirements, wound complications, and different types of skin lesions. The document also includes information on wound care interventions, dressings, and medications.
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Steps to heal by Secondary Intention - ✔✔Formation of granulation tissue, contraction of the wound bed edges, and epithelialization
Partial thickness repair - ✔✔Inflammatory response, epithelial proliferation and migration, epidermal reestablishment and differentiation
What characterizes a chronic wound healing environment - ✔✔Low levels of growth factors and receptor sites. They are needed to move cells out of the inflammatory phase and into the proliferative/Rebuilding Phase
What Vitamin assists in collagen/fibroplasia formation? - ✔✔Vitamin C
Normal protein intake - ✔✔.8 g/kg/
Protein intake for injury - ✔✔increased 1.25 - 1.5 /kg/24 hours
BMI >25 increases - ✔✔dehiscence, infection, delayed wound healing, adipose tissue poorly perfused and heals at a slower rate
Keloid Scars are formed how? - ✔✔Overgrowth of collagen within scar tissue, seen with pigmented skin. Trauma. May ulcerate. Genetic.
Hypertrophic Scar are formed how? - ✔✔scar with thickened epidermal layer contained within the original incision area. Formed from prolonged inflammatory phase.
Fast/rapid weight loss produces what type of malnutrition? - ✔✔Protein & mixed protein malnutrition: marasmus-kwashiorkor
Marjoin ulcer - ✔✔chronic wounds in malignant wound
Candidiasis - ✔✔Pustules and satellite lesions with red base
Incontinence associated dermatitis - ✔✔blisters with red base
Radiation Dermatitis - ✔✔Grade 1: Dry desquamation (Peeling)
Grade 2: erythema, moist desquamation (partial thickness), mod edema
Grade 3: Bleeding skin
Wheal skin lesion - ✔✔Itching, burning, red, elevated, irregular
Pyoderma Gangrenosum - ✔✔Ulcer with irregular shape and violaceous (purple) raised edges. Sharp debridement is contraindicated.
Calciphylaxix - ✔✔Calcific uremic arteriolopathy elevated calcium/phosphate. Dialysis. may present similar to Pyoderma. Aggressive sharp debridement for necrotic tissue.
Partial thickness wound - ✔✔shallow ,.2 cm, moist, pink/red wound base, exposure of basement membrane and of nerve endings. Epidermal/Dermal Loss
Epibole - ✔✔rolled skin edge that indicates slow healing. Prevents epithelialization and closure. Cauterization (silver nitrate) or surgical debridement
Elma (topical prilocaine/lidocaine) - ✔✔best 30-60 min under nonadherent transparent wrap for analgesia
PreAlbumin - ✔✔Maybe normal under states of malnutrition
Metronidazole (Flagyl) - ✔✔Crushed and used to control odor in fungating wounds (breast CA)
Cover partial thickness skin tears with - ✔✔Contact layer (nonadherent dressing)
Candidiasis Intervention - ✔✔prevent moisture buildup
miconazole nitrate powder 2%
Calcium Alginate Dressing - ✔✔Shallow to tunnels with moderate to heavy drainage
Surgical Sharp Debridement - ✔✔Non selective. Indicated for advancing cellulitis and wound related sepsis
Always culture - ✔✔Clean viable tissue not exudate or eschar
A wound that fails to progress as anticipated
Levine technique uses a normal saline moistened swab
Dankin's (sodium hypochlorite <0.5%) - ✔✔Removes slough and controls odor
Kenalog cream - ✔✔reduces hyperplasia
Regranex - ✔✔Platelet growth factor for foot ulcers
Unstageable Pressure Ulcer - ✔✔Full thickness with base covered in slough
Braden Scale - ✔✔>18-23 not at risk
15-18 mild
13-14 mod
10-12 high
<9 very high
PUSH Tool - ✔✔Pressure ulcer healing evaluated by size, exudate, and tissue type