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93 Cards in this Set
- Front
- Back
What is the largest organ in the body?
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skin (15% total body weight)
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epidermis
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top layer of skin
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dermis
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inner layer of skin
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pressure ulcer
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a localized injury to the skin and underlying tissue, usually over a bony prominence
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what is the major contributor to pressure ulcers?
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PRESSURE!!!
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blanching
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normal red tones of skin are absent.
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what happens If pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time?
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tissue ishemia
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low pressures can cause
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tissue damage
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extended pressure can cause
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cell death
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Impaired sensory perception
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cannot feel their body sensations.
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impaired mobility
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cannot change or shift their bony prominences
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friction
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force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface.
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alterations in LOC
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unable to protect themselves
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sheer
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force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface.
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moisture
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reduces skins resistance to other physical factors
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stage 1
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skin intact, non-blanchable redness
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stage 2
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partial thickness skin loss
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stage 3
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full thickness skin loss with visible fat
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stage 4
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full thickness skin loss with visible bone, muscle, or tendon
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Who defined pressure ulcers?
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NPUP
National Pressure Ulcer Advisory Panel |
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what is granulation?
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red moist tissue composed of new red blood cells= healing
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what is slough?
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yellow or white stringy tissue--> remove before healing can occur
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what is eschar?
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brown or black necrotic tissue --> also must be removed before healing
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what do we record when assessing wounds?
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-size of wound
-exudate (drainage) -surrounding skin's appearance |
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wounds
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disruption in skin integrity and function of tissues in the body.
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what are two methods of classification for skin wounds?
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describe status or skin integrity and describe qualities of the wound such as color
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when does primary intention occur?
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the edges are approximated or closed and risk of infection is low
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when does secondary intention occur?
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when the wound is left open until it becomes filled by scar tissue (Burn, pressure ulcer or severe laceration)
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when does tertiary intention occur?
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occurs when wounds are left open for several days and then closed or approximated (Infection)
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how does partial thickness heal?
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via the inflammatory response, epithelial proliferation, and migration with reestablishment of epidermal layers
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how does full thickness heal?
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via inflammatory response, proliferation, and remodeling
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what are complications of a wound?
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hemorrhage, infections, dehiscence, evisceration, and fistulas.
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s/s hemorrhage
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swelling
hypovolemic shock if internal. exudate change |
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s/s infection
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fever, tenderness, pain at wound site and elevated WBC
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s/s dehiscence
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note increased in sersanguinous drainage, BE ALERT FOR RISK OF DEHISCENCE.
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what do you do when someone with dehiscenence is coughing or getting up?
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USE A BLANKET OR PILLOW OVER SURGICAL SITE!!!
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s/s evisceration
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Place sterile towel soaked in saline over extruding tissues to reduce risk for infection.
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which complication is an emergency and requires surgical care?
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evisceration!!!
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s/s fistula
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result of poor wound healing and usually a complication of disease.
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prevention of pressure ulcers include...
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special beds and mattresses, good hygiene, good nutrition, adequate hydration, and impeccable nursing care.
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what 5 risk factors are on the norton scale?
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Physical and mental condition, continence, activity, and mobility,
pam and cam |
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what does the score range from on the norton scale?
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5-20
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what 6 risk factors are on the braden scale?
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Sensory perception, moisture, activity, mobility, nutrition, and friction and shear
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what does the score range from on the braden scale?
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6-23
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which one is more commonly used in a nursing home?
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braden
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what is tissue perfusion?
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tissue oxygenation fuels cellular function
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who is at risk for tissue perfusion?
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diabetes mellitus
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what can wound infection cause to the healing proccess?
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inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction
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what can age cause to the healing process?
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inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction
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what are nutritional requirements for wound healing?
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clients need 1500 kcal/day
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what are some assessment guidelines for skin intergrity?
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Skin
ulcers Mobility Nutrition Pain wounds Wound culture wow pm sun :) |
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what are some interventions for pressure sores?
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turn 1-2 hours, clean and protect bony prominences, dont raise HOB over 30 degrees.
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what is the key to implementation?
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health promotion and prevention
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what do support surfaces do?
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Decrease the amount of pressure exerted over bony prominences.
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how often should you turn patient?
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1-2 hours minimum
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what else does skin contribute to the body?
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makes vitamin d
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what do we do to aid the pressure ulcer?
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reduce pressure
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what are you ischemial tuberosities?
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butt bones
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who does blanching not occur in?
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dark skinned clients
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are all wounds created equal?
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NO!
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on the braden and norton scales, what score = a higher risk for pressure ulcer?
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low scores
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debridment is
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cleaning our the wound
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what are some types of debridment?
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mechanical, autolytical, chemical, or surgical/ sharp
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mechanical
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example is wet to dry saline gauze dressing or whirlpool treatments
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autolytical
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use of dressings over a wound to allow eschar to be self-digested by action of enzymes (Hydrocolloid, transparent dressings)
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chemical
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use of topical enzyme preparations or sterile maggots. It breaks down the necrotic tissue
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surgical/ sharp
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removal of devitalized tissue by using scapel or scissors
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who do we need to educate on acute care?
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client and client's family
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hemostasis
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control bleeding by holding direct pressure
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what do we need nutritionally for wounds?
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protein
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who will decrease if protein is low?
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serum albumin and hemoglobin
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who is the preferred cleaning agent by WOCN?
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normal saline
(wound,ostomy, and continence nurses society) |
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what are the purpose of dressings?
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Protect
healing Supports site moist environment. |
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what is a dry or moist dressing?
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gauze
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what does hyrdrocolloid do?
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Protects the wound from surface contamination
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what does hydrogel do?
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Maintains a moist surface to support healing
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what does wound V.A.C do?
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Uses negative pressure to support healing
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what are some ways of securing dressings?
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tapes, ties, and binders
(DONT PUT BINDERS TOO TIGHT!) |
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what do we offer before dressing changes?
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pain meds
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how do we clean wounds?
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area least contaminated to outside skin
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what does irrigation do?
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Removes exudates, use sterile technique with 35-ml syringe and 19-gauge needle
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what do we assess with bandage/binders application?
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inspect skin for abrasions, edema, discoloration, open wounds, circulatory impairment (coolness, pallor, cyanosis, pulses, swelling, numbness or tingling).
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why heat?
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arthritis, joint disease, muscle strain, menstrual cramping, hemorrhoid, perianal inflammation or abscess.
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why cold?
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sprain, strain, fracture
muscle spasms, laceration, minor burn, arthritis, post-injection or joint trauma. |
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what are the fat soluble vitamins?
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adek
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do we massage bony prominences?
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no
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dont postion on bony prominences or..?
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a donut pillow
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what can decrease wound healing?
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smoking ( decrese hemoglobin --> o2 to tissues)
chemo and radiation therapy some drugs (decrease immune response) |
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what is vitamin c in?
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citrus fruits (collagen)
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what foods have protein?
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meat, fish, ..?
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what has vitamin a?
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liver
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what is vitamin a good for?
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skin and reverse steroid effects on skin
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what is in folic acid?
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b vitamins
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