Background, Healing, Closure, Screening/ Exam Flashcards
What are the functions of the integumentary system?
o “Serves as a barrier to environmental threats such as bacteria, pressure, shear, friction, & moisture”
(Guide to PT Practice)
o Protection/immunity - protects against pathogens, decreases water loss
o Temperature regulation – provides insulation, related to dilation & constriction of blood vessels, sweating
o Sensation – contains various nerve endings, including for pain, light touch, etc
o Assists in VitD synthesis, indicator of VitB levels
Layers of the integumentary system
epidermis
dermis
hypodermis
Layers of the epidermis:
stratum corneum
stratum lucidum
stratum granulosum
stratum spinosum
stratum basale
basement membrane
stratum corneum (epidermis)
-most superficial- primary barrier
-soft keratin-containing, dead squamous cells
-constantly sloughing or shedding
-15-20 layers of dead cells
-can indicate hydration levels
stratum lucidum (epidermis)
-thin, clear layer of dead skin cells
-palms of hands and soles of feet (increased tissue stress areas)
stratum granulosum (epidermis)
layer that contains the transition zone for the development of keratin
-active keratin development
Stratum spinosum (epidermis)
-layer containing spiky or spiny projections
stratum basale (epidermis)
deepest and most continuous layer of the epidermis
1-3 layers of cells thick
regenerates the epidermis –> everything above it
contains a variety of other cells
CELLTYPES: basal cells, keratinocytes, merkel cells melanocytes,
Basement membrane (epidermis/dermis)
layer that separates the epidermis and dermis
Epidermal cell types and appendages
o Melanocytes – produce melanin
–> found in stratum spinosum and stratum basale
o Merkel cells – mechanoreceptors for light touch sensation
–> found in stratum spinosum
o Langerhans’ cells – fight infection
–> found in stratum spinosum
Functions of the dermis
-thickest layer of the skin
FUNCTIONS
▪ Thermoregulation
▪ Storage of water/maintaining hydration
▪ Provides nutrients & waste removal for itself & the epidermis
▪ Houses the epidermal appendages
▪ Assists with infection control
▪ Provides sensation
-hair, nails, sweat glands, and sebaceous glands
What does the dermis contain?
-blood vessels
-lymph vessels
-nerve endings
-epidermal appendages
–> hair
–> sebaceous glands: slow down growth of bacteria; secrete sebum
–> sudoriferous glands–> sweat glands
–> nails
Regions of the dermis
PAPILLARY REGION
-bumpy surface that interdigitates with the epidermis, strengthens the connection
-influences the contours of the skin’s surface
-ex: fingerprints
RETICULAR REGION
- Contains collagen, elastic, & reticular fibers, providing strength, extensibility, & elasticity
- Contains the roots of the hair, sebaceous & sweat glands, receptors, nails, & blood vessels
Hypodermis characteristics:
-subcutaneous tissue
-attaches skin to underlying bone and muscles
-contains loose CT, adipose tissue, and elastin
-contains 50% of body fat
-provides insulation and shock absorption
-Pacinian cells (vibration, deep pressure, proprioception) and free nerve endings for cold and pressure
What is a pacinian cell?
Pacinian corpuscles, also known as Vater-Pacini or lamellar corpuscles, are sensory receptors for vibration and deep pressure and are essential for proprioception
-found in the hypodermis
Why do we care about the integumentary system/wound care?
skin abnormalities–> can indicate more global disease
appearance and quality can indicate overall health
-PT can specialize in wound care
-profound effects on our patients and on the healthcare system
Risk factors for inadequate wound healing:
-comorbidities
-nutrition or malnutrition –> appropriate protein and calorie intake
-obesity- extra tissue gets less blood flow the further out the tissue has to go
-smoking, alcohol, and/or drug use
-sedentary or limited mobility
-impaired sensation
-risk-prone behavior
Extrinsic factors impacting wound healing:
-shoes - condition and fit
-orthotics and prosthetics
-seating
-hairstyles
What kinds of health conditions can impact the integumentary system?
cardio - venous/arterial insufficiencies
endocrine/metabolic - DM
neuromuscular
integumentary- burns, frostbite, incisions
MSK
pulmonary
multisystem/other
Impairments of the integumentary system:
de-conditioning
claudication, tissue perfusion
skin lesions, adhesions, scars
sensory integrity
Wound healing chronology:
1.) inflammation
-longest stage
-peaks at 1-3 days
2.) proliferation
-peaks at 10 days
-overlaps with the inflammatory phase
-Also known as angiogenesis, this phase occurs when the wound is rebuilt with new tissue made of collagen and extracellular matrix.
3.) maturation- Also known as remodeling, this phase occurs when the wound fully closes and collagen is remodeled. This phase also involves scar tissue formation.
Hemostasis process:
1.) vessel injury
2.) vascular spasm with infiltration of platelets - smooth muscle contraction
3.) formation of the platelet plug - Fibrinogen converts to fibrin, the fibrin threads weave and stick together over the top of the platelet plug and hold the clump in place.
4.) the coagulation- fibrin filaments, red blood cells, and white blood cells the blood clot it formed ; fibrin strands secure the platelets and RBCs, effectively plugging the break (clot)
Infection control in the integumentary system:
- bacteria and other pathogens enter wound
- platelets from blood release blood clotting proteins at wound site
- Mast cells secrete factors that mediate vasodilation and vascular constriction. Delivery of blood, plasma, and cells to injured area increases
- Neutrophils secrete factors that kill and degrade pathogens
- Neutrophils and macrophages remove pathogens by phagocytosis
- Macrophages secrete hormones called cytokines that attract immune system cells to the site and activate cells involved in tissue repair
- inflammatory response contributes until the foreign material is eliminated and the wound is repaired
Inflammatory phase of wound healing:
o Requires a vascular & cellular response from living tissue
o Assists in controlling the bleeding & combating infection
o Sets the stage for further healing by signaling the cells for repair & regeneration
Characteristics: erythema, edema, tenderness, pain
Function: remove debris, start healing cascade and prepare wound for regeneration
Timeline: begins at injury and lasts a few days
-1: injured blood vessel walls allow transudate to leak into the interstitial space (local edema) –> helps with fluid leakage
-2: local blood vessels constrict for several minutes to reduce blood loss
-3: platelets aggregate at the injury site, become active and start sticking together
◦ Activated platelets release chemicals like cytokines (proteins), growth factors (for cell growth,
differentiation, metabolism), & chemotactic agents (attract cells for wound repair)
Cellular response in inflammatory phase of wound healing:
PMNs (polymorphonuclear neutrophils) - scavengers that kill bacteria and cleans wound
Macrophages - direct the repair process, assist with killing bacteria and cleaning wound, secretes growth factors
Mast cells - secretes enzymes and inflammatory mediators
Proliferative phase of wound healing
Timeline: begins around 48 hours, for weeks
Processes:
-angiogenesis (neovascularization)- capillaries form buds and grow
-granulation tissue formation- temporary latticework of vascularized CT to fill wound; eventually replaced by scar tissue; healthy, new tissue
-wound contraction- myofibroblasts drive this process, pulling wound edges together –> more for full thickness wounds, slower in circular wounds
-epithelialization - keratinocytes at wound margins and epidermal appendages begin to multiply and migrate –> closed barrier of wound
** unable to migrate over nonviable tissue
Epitheliaziation process of wound healing
-Epithelial cells migrate across the new tissue to form a barrier between the wound and the environment
-Basal epithelial cells at wound margin
–> multiply in horizontal direction
–> epithelial cells move toward and fill the edges of the wound and form a layer of cells
–> flatten (mobilize) and migrate into the open wound
-Basal cells behind margin undergo vertical growth (differentiation)
Remodeling phase of wound healing
-new collagen is formed
-old collagen broken down
-Collagen fibers from immature Type III to mature Type I
AND reorient along the lines of stress
-rosy, pink scar–> more pale with remodeling
-sensation, oils, sweat may be different after wound
-tissue never returns to same as it was before wound
-Timeline: Remodeling can continue for up to 2 years following wound closure, with the greatest change in the first 6-12 months
-Increase tensile strength over time, but never back to baseline (only 80%)
Primary intention wound closure:
clean, straight line, edges well approximated with sutures, rapid healing, usually best cosmetic outcome
Secondary intention wound closure:
larger wounds with tissue loss, edges not approximated, heals from the inside out, granulation tissue fills in the wound, longer healing time, larger scars
-wound left open and allowed to heal spontaneously/ fill
-contaminated/infected wounds
-increased scarring
**wound care PT more directly invovled
Tertiary intention wound closure:
delay is typically 3-5 days before injury is sutured, used to manage infected or unhealthy wounds, larger scar
-delayed primary closure
-good for contaminated/infected initially wounds
What are some examples of abnormal wound healing?
oAbsence of inflammation
oChronic inflammation
oHypogranulation
oNon-advancing wound edge (epibole)
oHypergranulation
oHypertrophic scaring
oKeloids
oContractures
oDehiscence
What types of characteristics should you note in a wound?
◦ Mechanism of onset
◦ Time since onset
◦ Wound location
◦ Wound dimensions
◦ Wound temperature
◦ Wound hydration
◦ Necrotic tissue and/or foreign bodies
◦ Infection
local factors that affect wound healing:
circulation
sensation
mechanical stress
Systemic factors that impact wound healing:
◦ Nutrition/hydration
◦ Diabetes
◦ Peripheral Vascular Disease (PVD)
◦ Gastroesophageal Reflux Disease (GERD)
◦ Collagen disease
◦ End Stage Renal Disease (ESRD)
◦ Immunosuppression
◦ Aging
◦ Medications
◦ Social/health habits
◦ Functional status & activity level
◦ Infection
◦ Paresthesia
◦ Perfusion
◦ Incontinence
Blanchable vs non-blanchable:
Blanchable: reddened area that turns pale under applied light pressure.–> GOOD
Non-blanchable: an area of redness that does not blanch under applied light pressure.–> more significant tissue involvement
Cyanosis vs Purple color vs red
cyanosis- lack of oxygen perfusion
purple: deep tissue injury
red: infection, inflammation, cellulitis, dermatitis, erythema, stage 1 pressure injury, 1st degree burn
Cellulitis appearance vs dermatitis
CELLULITIS: (fat and shiny)
DERMATITIS: raised bumps, red
Skin observations in color:
white:
-reynaud’s –> keep in mind how this looks different in different skin colors
black:
-necrotic tissue: eschar, gangrene
Yellow: jaundice: liver issues
Characteristics of skin color and texture:
-varies with wound type
-indicates what’s happening beneath the skin
-changes –> may indicate infection
-helps determine which tests are indicated
-signs of integument disease
what is edema?
o Defined as excess fluid in the interstitial tissue
o Can be multi-factorial in cause
o Impedes healing regardless of etiology
o Extent and type of edema helps identify wound etiology.
Localized edema:
-infection
-inflammatory response in the immediate wound area
Unilateral edema
-DVT
-venous insufficiency
-IV fluid going to incorrect place
-had surgery that affected the lymphatic system
Bilateral edema could indicate what?
you could be suspicious of a condition that is more systemic
How do we grade pitting edema?
Trace- 1+ < 2mm and barely perceptible
Mild - 2+
Moderate - 3+
Severe- 4+ > 7mm and > 30 seconds
Based on amount of depression and time before skin rebound
What is induration (edema)
skin that looks like an orange peel
extreme edema; chronic
hard and firm
Signs of acute inflammation:
◦ Rubor – redness
◦ Fumor – swelling
◦ Calsor – heat
◦ Dolor – pain
◦ Functio laesa – loss of function
Signs of infection:
odor
pain -throbbing
palpation - pain
systemic changes
wound cultures
-streaking: sepsis
-more drainage from the wound–> infection
** all of the signs of inflammation but more extreme
Wound cultures:
-gold standard for tissue biopsy
-swab cultures: find number & type of bacteria present
–> bacteria types: aerobic (common most wounds) and anaerobic (deep, tunneling wounds, wounds with undermining or sinus tracts, wounds occluded with thick layers of topical agents)
-fluid aspiration: must have enough fluid to sample, middle ground between biopsy and swab
Ways to manage infection:
-antibiotics
-antibacterials (e.g., Bacitracin, Bactroban, Silvadene, Neosporin)
-antifungals (e.g., Mycostatin, Lotrimin)
-antiseptics (e.g., acetic acid, Hibiclens, Dakin’s solution, hydrogen peroxide, Betadine)
INFLAMMATION VS INFECTION
INFLAMMATION
-slight edema
-local temp inc.
-mild amount drainage, thin, clear fluid
-well defined erythema near wound edges
-pain proportionate to wound
INFECTION
-significant edema
-broad temp increase, hot to touch, fever, malaise
-large to copious drainage, prurulent or clear, thin or thick
-broad, streaking redness, blistering clear or blood filled
-severe pain, no position of comfort, change or disproportionate
Two ways to diagnose wounds:
1.) by tissue involvement - local care
-superficial/erosion
-partial or full thickness
2.) by etiology - systemic care
-arterial wound
-venous wound
-neuropathic wound
-pressure injury
-atypical
Questions to ask about wound itself:
-any precipitating event associated with the onset of the wound?
-other signs/symptoms? (fever, itching, pain)
-what alleviates the pain/makes worse?
-what have you tried for treatment?
-is wound getting better or worse?
Questions about patient:
PMH
Current meds
Allergies
Nutritional Status
Alcohol, tobacco, drug habits
Physical Activity Level?
AD required for functional activities?
Other social history that may be pertinent- religious beliefs, culture, etc.
Objective Measures to include in wound exam:
-dimens./extensions
-tissue type
-staging
-wound bed color
-drainage
-wound edges
-check surrounding tissue
-temperature
-edema
-circulation
-circumferential measurements
-sensory integrity
Taking dimensions of a wound: (head to toe method)
Length (cm) x width (cm) x depth (cm)
** always use a decimal point
** length: head to toe
**width: 9 to 3
EX: tunneling at 3 o’clock, 1 and 7 length
Clock method:
-used for tunneling and undermining
Methods for taking dimensions:
perpendicular
clock
volumetric - measure how much saline it takes to fill the wound
tracing-clear film, draw on with permanent marker, gives you an idea of the size of the wound and compare how that is changing
photography- use grid method to determine the size of the wound
–> ex: “” squares in this direction
–> keep image a consistent distance away from the wound
How to take total body surface area- burns:
rule of 9s
-head and neck: 9 percent
-anterior trunk (chest and abdomen): 18 percent
-posterior trunk (back and buttocks: 18
upper extremities: 18- each arm front and back
lower extremities: 36 percent: each leg 9 percent front and back
genitalia and perineum: 1 percent
What are the types of subcutaneous extensions ?
tunneling/sinus tract - narrow passage of tissue destruction within wound or separation of fascial planes
-into wound bed
undermining - destruction of CT between dermis and subcut. tissue
-extends under the intact skin along the periphery of a wound
fistula - tunneling that connects with a body cavity –> ** refer immediately!!
MEAUSREMENTS:
-ex: tunnel at 7 oclock and measures 3 cm (depth)
-undermining at 11 oclock to 2 oclcock
Abrasion
-rubbed/scraped skin
-usually not much bleeding
EX: road rash
Avulsion
-partial or complete tearing away of skin/tissue
-bleeds heavily and
rapidly
MOI: accident, crush accident, explosion, gunshot
Puncture
small hole caused by pointy object
may not bleed much, can damage organs
MOI: nail, bullet, needle
Laceration
Deep cut or tearing of skin
rapid and extensive bleeding possible
MOI: knives, tools, machinery
Why do we need to determine tissue type?
-find out healing phase
-provide data for measuring outcomes
-determine optimal treatment plan for primary and secondary dressings
-indicate other disease processes
Granulation tissue:
red, beefy
-caused by angiogenesis
-made of new capillaries and ECM
-varies in color from anemic –> bright red
-necessary for secondary intention wound closure or split thickness skin graft
**Carefully protected in good wound management
What is a split thickness skin graft?
A split-thickness skin graft (STSG), by definition, refers to a graft that contains the epidermis and a portion of the dermis, which is in contrast to a full-thickness skin graft (FTSG) which consists of the epidermis and entire dermis
Slough
-type of NECROTIC tissue
-softer, lighter necrotic debris
-by-product of autolysis
-usually beneath eschar
-more common in inflammatory phase of healing
-soft and mushy, sometimes hard to grasp with forceps ; different from CT that is adhered to dermis
**this needs to be removed for healing
Necrotic tissue
composed of dead cells and fibrin
may be dray and hard or soft, rubbery, leathery
-may be dry gangrene or wet gangrene
what is gangrene?
-tissue death due to interrupted blood supply
-type of necrosis
DRY
-Dry gangrene can result from conditions that reduce or block arterial blood flow such as diabetes, arteriosclerosis, and tobacco addiction as well as from trauma, frostbite, or injury.
WET
-Wet gangrene can result from the same causes as dry gangrene but always includes infection. In some cases of wet gangrene, the initial cause is considered to be the infection.
** INFECTION
What does muscle look like when unhealthy?
brownish-gray or black when devitalized (rich blood supply)
painful when exposed
Appearance of tendons:
-shiny and stringy when healthy
-dull and dry, leathery when devitalized
-covered with fibrous sheath of CT containing synovial fluid or fatty fluid (paratenon)
-may see movement of tendon with movement of patient
Appearance of bone: normal and abnormal
NORMAL: tan, milky, white in color; shiny
NECROTIC: dark brown, soften, appear moth-eaten
–> must be debrided if necrotic
-covered with periosteum when healthy
Appearance of adipose tissue: normal and abnormal
purpose:
-stores fat, provides energy, cushioning, insulation
-stores fat soluble vitamins like A,D, E, and K
NORMAL: shiny, yellow-white globules when healthy
DEVITALIZED: shriveled and dry
** frequent source of abscess formation
Classification of skin loss:
erosion- loss of epidermis
partial thickness- loss of epidermis and part of dermis
full thickness- loss of all of the epidermis, dermis, into subcutaneous tissue
Staging of pressure injuries:
STAGE 1
-no opening of wound
-NOT blanchable
STAGE 2
-opened wound
-shallow
-outer layer of skin affected
-partial thickness
STAGE 3
-full thickness wound
-tunneling and undermining is possible
-cannot see ms., tendon, or bone
STAGE 4
-tunneling and undermining is possible
-slough and eschar possible
-full thickness
-CAN see ms., tendon, or bone
UNSTAGEABLE: cannot see the bottom of the wound –> could be covered by eschar
What is a deep tissue pressure injury?
-not enough adequate blood supply
-likely to open to stage 3 and 4 pressure injury
-can look like a blood blister
-NOT blanchable
-DARK, purple in color
-ultrasound may be good intervention
-very common in falls at home
