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Wound Care WOCN: Questions & Detailed Answers
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Wound Care WOCN: Questions & Detailed AnswersTEWL Right Ans - Transepidermal water loss
What is the most common type of skin cancer? Right Ans - basal cell
carcinoma (BCC)
How does basal cell carcinoma present? Right Ans - "pearl like" translucent
papule with central ulceration
What is the second most common type of skin cancer? Right Ans -
Squamous cell carcinoma (SCC)
How does squamous cell carcinoma present? Right Ans - Enlarging
keratotic papule
ABCDEs of melanoma Right Ans - Asymmetric, border irregular, color
variance, diameter >0.6 cm, evolution
What is the order of repair in an acute wound? Right Ans - Brief
inflammatory phase, epithelial resurfacing and granulation tissue formation
and remodeling
What is the max tensile strength for a full-thickness wound healing by scar
tissue formation? Right Ans - 80% of original tissue strength
What strategy is used to help convert a chronic wound into an acute wound?
Right Ans - Surgical debridement
intermittent claudication Right Ans - pain and discomfort in calf muscles
while walking; a condition seen in peripheral arterial disease
What are the nutritional requirements of patients with open wounds or at risk
for pressure ulcer? Right Ans - 30 to 35 cal/kg/day; 1.25 to 1.5
proteins/kg/day; and 30mL/kg/day of fluids
Moisture retentive dressings Right Ans - permit evaporation of moisture
from the skin ad wound--NOT OCCULSIVE
, TIME framework for wound healing Right Ans - tissue management,
control of inflammation/infection, moisture balance, edge advancement
Appropriate wound cleansers that flush away exudate without damaging
proliferative cells include: Right Ans - saline, commercial wound cleansers,
and potable tap water
Cleansing of "dirty" wounds Right Ans - Require 4 to 15 psi irrigating force
and may involve cytotoxic solutions
contact layers Right Ans - 1. single layer of woven net
2. protects new granulation tissue
3. can irrigate through it
4. can use with topical med
5. needs a secondary dressing
6. not to be used with think exudate
Hydrocolloid dressing Right Ans - Inappropriate for infected wounds and
exudative wounds.
transparent adhesive dressing Right Ans - semipermeable, bacteria do not
penetrate the wound.
When is debridement contraindicated? Right Ans - In a closed uninfected
wound that is poorly perfused and when the goal of care is maintenance or
comfort as opposed to healing
surgical debridement Right Ans - The use of scalpels, scissors, or lasers in a
sterile environment by a physician or podiatrist to remove necrotic tissue,
foreign material, and debris from the wound bed. Debridement to the point of
bleeding may stimulate healing via the release of platelet-derived growth
factors.
autolytic debridement Right Ans - using body's enzymes to break down
tissue; Requires a moist wound surface and normal WBC counts (no infection)
Enzymatic debridement Right Ans - topical application of enzymes to
surface of necrotic tissue. can be used on infected and non-infected wounds
with necrotic tissue. may be used in wounds that have not responded to
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