Download Wound test 1 wocn Question With Verified Solution 2024 Osteomylitis treatment - ✔✔Referra and more Exams Nursing in PDF only on Docsity!
Wound test 1 wocn Question With Verified Solution
Osteomylitis treatment - ✔✔Referrals Pathway topical therapy - ✔✔Indicators osteo Ss of infection Ss of colonization aggressive cleaning. Antimicrob dresisng Periwound Wound edges open or Epibole Bed neurotic? Not neucrotic dressing based on volume of exudate and context and volume of wounds dressing functions - ✔✔Passive support for healing Surface wound with no depth - ✔✔Cover dressing only exudative - ✔✔Alginates Hydro fibers Polymers Foams Maintain hydration/ minimal exudate/ keeps moisture - ✔✔Hydrocolloids Transparent adhesive dressing Contact later dressing Moisture vapor transport rate (MVTR) - ✔✔a measure as to how quickly moisture vapor moves from the fabric side next to the body to the exterior ( hydrocolloids no MVTR) they trap moisture
Hydrocolloids - Indications - ✔✔Protection of partial thickness wounds with mild exudate, maintaining a moist wound environment. Form a gelatinous mass over the wound bed. Treatment of dry wounds - ✔✔Gels Dry crusty surface - ✔✔Need hydrating dressing - gel dressing selection considerations - ✔✔Depth Contours (tunnels or undermining Volume or exudate The first E in ESPE stands for - ✔✔Etiologies factors The s in ESPE stands for - ✔✔Systemic support The P in ESPE stands for - ✔✔Principle based topical support The 2nd E in ESPE stands for - ✔✔Evaluation Proliferative phase - ✔✔Evidence of clean wound base but lack of granulation tissue inflammatory phase - ✔✔Evidence of necrotic tissue If erythema does not extend beyond wound margins - ✔✔Not infected but just unprotected skin due to moisture
How many days is proliferation phase - ✔✔Starts on day one and ends 21- 30 Secondary intention full thickness PI order of healing - ✔✔Inflammatory- prolonged Granulation tissue Epithelial resurfacing Remodeling One clinical characteristic of a chronic wound - ✔✔Elevated levels of matrix metalloproteinases MMPs Higher levels of proinflammatory cytokines Greater number of senescent cells senescent cells - ✔✔Cells that do not respond normally to cytokines and growth factors regulating the repair process Order of repair by secondary intention - ✔✔ What 2 layers heal by regeneration - ✔✔Epidermal loss and partial dermal loss Fetal repair - ✔✔2nd trimester Heals by scar formation - ✔✔Deep dermal and appendages and subcutaneous layer and muscle and bone Partial thickness repair process - ✔✔Brief inflammation (crust formation ) Epithelial resurfacing Phases of chronic wound repair - ✔✔Prolonged inflammatory phase
Granulation tissue formation Epithelial resurfacing Remodeling Phases of acute wound healing - ✔✔1.Hemostatis-bleeding - growth factors 2.Inflammation- to establish clean wound bed 3.Proliferative - epithelial resurfacing/granulation formation 4.Maturation What phase does contraction occur in a full thickness wound repair - ✔✔Proliferative phase Are the only cells able to synthesize connective tissue repair - ✔✔Fibroblast Parts of Proliferative phase in full thickness acute wound. - ✔✔Epithelial resurfacing Granulation tissue formation Contraction Only occurs in open wounds not closed incisions - ✔✔Contraction Factors affecting tissues ability to redistribute pressures and tolerate ischemia - ✔✔Muscle and soft tissue wasting Vascular disease Hypotension Fever Edema Stress Smoking
Clues to etiology of wounds - ✔✔Location Depth contours and wound bed Patient history A friction injury usually occurs in: - ✔✔Freshly areas exposed to rubbing systemic factors affecting wound healing - ✔✔Nutritional status Perfusion status Lower extremity wounds Glucose control Steroids/cytotoxic agents Comorbities Each drawing change document - ✔✔Appearance of wound bed Type and amount of exudate Any signs of infection Procedure and pt response Weekly comprehensive wound. Documentation What phase is slough and Eschar in - ✔✔Inflammatory phase High volume exudative malodorous drainage - ✔✔Indicative of infection - anaerobic Signs of invasive wound infection - ✔✔Erythema extending > 2cm Induration warmth tenderness Impact of ischemia/immunosuppressive
Fever/leukocytosis Surface infection signs - ✔✔Sudden plateau deterioration of wound New or recurrent film on wound surface stage 2 pressure ulcer - ✔✔No granulation tissue No slough or eschar No exposed fat or muscle Can stage wound partially obscured by necrotic tissue if - ✔✔Muscle tendon or bone visiable then stage 4 No stage for healing granulation tissue - ✔✔Stage 2 does not Granulate when to debride - ✔✔Anytime goal is to repair Anytime wound is already open When wound is clinically infected even if goal is maintained or comfort( to reduce pain and odor) CSWD contraindications - ✔✔In infected wounds Enzymatic debridement on infected wound only if - ✔✔Pt on systemic antibiotics chemical debridement - ✔✔Good choice of necrotic infected wounds Chemical debridement agents - ✔✔Dakins 0.0125, 0.025%, didaksol,Ana sept,microcyn, puracyn, vashe
