class 3: integumentary Flashcards
what is the largest organ in the body
the skin
what is the primary function of the skin
Protection, insulation, holding organs together, sensory, fluid
balance, temperature control, absorbing UV radiation,
metabolizing vitamin D, and synthesizing epidermal lipids
what are the three layer of the skin
epidermis, dermis, and hypodermis
what are the cells found in the epidermis
Keratinocytes, Melanocytes, Langerhans Cells, Basal Cells
what are the cells found in the dermis
Collagen, Reticulum, Fibroblasts, Macrophages, Lymphatic Glands,
Blood Vessels, Nerve Fibers
Meissner’s Corpuscles
Detect light touch and texture
Merkel Disks
Detect light touch, texture and pressure
Ruffini Endings
Detect warmth, stretch, deformation
within joints
Free Nerve Endings
Detect pain, temperature, touch, pressure,
tickle and itch
Krause End Bulbs
Detect cold temperatures
what is Herpes Zoster
a painful skin rash caused by the varicella-zoster virus (VZV), the same virus that causes chickenpox
what are the initial symptoms of hepres zoster
pain and paresthesia localized to the affected dermatome
what are the sym associated with hepres zoster
*Present as painful rash with clusters of fluid filled
vesicles
*Raised to palpation (< 2 mm height)
*Pink with silvery white appearance
is hepres zoster uni or bilateral normally
unilateral
what is Venous insufficiency:
Refers to inadequate drainage of venous blood from a body part,
usually resulting in edema and/or skin abnormalities and
ulcerations.
what is Arterial insufficiency:
Refers to a lack of adequate blood flow to a region of the body.
Venous Insufficiency - clinical presentation location
Proximal to the medial malleolus
Venous Insufficiency - clinical presentation apperance
*Irregular, shallow appearance
- Flaking, brownish discoloration-
Hemosiderin staining
Venous Insufficiency - clinical presentation pain
- Mild to moderate pain
- Elevation decrease pain
Arterial insufficiency - clinical presentation location
Lower 1/3 of leg, toe, dorsum of
foot, lateral malleolus
Arterial insufficiency - clinical presentation apperance
Smooth edges, well defined, tend to
be deep
Thin and shiny, hair loss, yellow
nails
Arterial insufficiency - clinical presentation pain
- Severe pain
elevation increases the pain
is Intermittent claudication see with Venous Insufficiency or Arterial insufficiency
Arterial insufficiency
where are pressure injuries located
over bony pressure areas and
Stage 1 - pressure ulcer
Intact skin with non-blanchable redness
stage 2 - pressure ulcer
partial thickness wound. Superficial in nature with pink/red wound
bed (shallow crater)
stage 3 - pressure ulcer
full thickness wound. Subcutaneous fat tissue visible but no bone,
tendon and muscle exposed (deep crater)
stage 4 - pressure ulcer
full thickness with exposed bone, tendon or muscle. Undermining and
tunneling with slough/eschar present.
unstagable - pressure ulcer
wound bed covered with slough/eschar (unable to identify the
depth)
deep tissue injury - pressure ulcer
Intact skin purple maroon appearance
where are Diabetic ulcers located
are generally located on the
weight-bearing surface of the foot.
where are Venous insufficiency ulcers
frequently are proximal to the medial malleolus.
They are edematous.
what is edematous.
abnormally swollen with fluid, or relating to or affected with edema.
where are Arterial ulcers
are generally located on
lateral malleolus, distal toes, or areas of trauma.
what are Pressure ulcers due to
are the result of unrelieved
external pressure on an area.
how do we measure a wound
Length x width x depth using a disposable ruler
what can used to detect the depth of the wound
A disposable cotton swab can be used to assess thedepth
what is Granulation tissue
with herpes zoster what CN are effected
CN 3 - oculomotor
CN 5 - trigeminal
what are the precaution to be taken when some has herpes zoster
airborne and contact precautions
what are airborne precautions
apply to patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei.
N95 and wash hands
what are contact precautions
gloves, gown, and wash hands
what is Necrotic tissue
dead or dying tissue that can no longer function normally
what are the two words used to describe the edge of the wound
indurated - harder, thin or thick
epibole - rolled
what is cellulitis
bacterial infection that affects the skin’s deeper layers and underlying tissue
what is the apperance of cellulitis
Redness, swelling, pain, tenderness, warmth, and a rash that may blister and scab over
what is the Periwound:
the surrounding of the wound
what is dermititis
inflammation of the skin
sometime we see bislters
what is the mode of tranmission for herpes zoster
airborne
what is herpes simplex 1
fever blister/cold sore
mostly spreads by oral contact and causes infections in or around the mouth (oral herpes or cold sores)
contact precautions
what is herpes simplex 2
normally effects in the genital area
contact precaution - spread via contact
what precaution do we use for dermitisis
contact precautions
what is Maceration 2/2
If a wound is too moist, the edges and periwound will become macerated
Inappropriate wound care, uncontrolled wound drainage,
perspiration, or incontinence
what is Maceration
A condition that occurs when skin softens and breaks down due to prolonged exposure to moisture.
too long in the bath
what is pustules
mall, inflamed, pus-filled blisters that can appear on the skin. there is pus inside the
acne, small pox
what is vesicles on skin
small, fluid-filled blisters that can appear on the skin.
chicken pox
< .5
what are wheals
raised, red, itchy bumps that are a common symptom of hives, or urticaria
splotchy
what does Maceration look like
It is identified as white, friable, overhydrated, and sometimes
wrinkled skin
what is the size of a blister
<.5 cm
what is a blister called if it is greater then .5 cm
bullae
found on the skin or to air-filled cavities in the lungs
what is Desiccation
the state of extreme dryness, or the process of extreme drying.
what cause Desiccation
If a wound lacks moisture, the wound and periwound will become dessicated
Inappropriate wound care, inadequate moisture, infection,
dehydration.
what does wound Desiccation look like
It is identified as cracked, with dry or flaky edges, and the tissue
within the wound bed may be hard or crusty.
Debridement - selective what is being removed
Removal of only nonviable tissues from a wound
what are the three types of Debridement - selective
Sharp debridement:
Enzymatic debridement:
Autolytic debridement:
what is hyperkeratosis
a condition that causes thick, rough patches of skin
think of the bottom of your feet
what is used for Sharp debridement:
Use of scalpel, scissors, forceps
what is used for Enzymatic debridement:
Use of a topical application of enzymes
what are used for Autolytic debridement:
Use of the body’s own mechanism to remove nonviable tissue
a natural process that breaks down dead tissue at a wound site using the body’s own enzymes and cell
what is Nonselective Debridement
Removal of both nonviable and viable tissues from a wound
what is the claudication scale numbers
1-4
claudication scale 1
discomfort or pain only at modest levels
claudication scale 2
moderate discomfort where the pt can be distracted from the pain
claudication scale 3
intense pain, attention cannot be diverted
claudication scale 4
unberable pain
what are Nonselective Debridement methods
Wet to dry dressings:
Wound irrigation:
Hydrotherapy:
what is the intervention for cluadication PT
intermittent waking program
walk until grade three - intense pain
then make the pt rest until the pain goes away and then walk again
40-60 min of walking
what are Wet to dry dressings:
Application of a moistened gauze over area of necrotic tissue
to be completely dried and removed
what is Wound irrigation:
Moves necrotic tissue from wound bed using pressurized fluid
what is Hydrotherapy:
Using a whirlpool with agitation directed toward a wound requiring
debridement
Very mild exudate - example
Transparent films
Minimal exudate - example
Hydrogel dressing, Hydrocolloid
Moderate exudate: example
Foams
what stage do we start to see slough in pressure wounds
stage 3 onwards
stage 3 pressure wound strtucture
fat
stage 4 pressure wound structure
bone, muscle tendons
Heavy exudate: examples
Calcium alginates, Hydrofiber (max capacity)
what stage of pressure ulcer do we see underminding and tunneling
stage 4
what do we use on infected wounds
Hydrofiber, Hydrogels, Calcium alginates, and Gauze
what do we do with red wounds
cover the wound
keep it dry and clean
use a transparent dressing over gauze moistened with saline
or use hydrogel, hydrocolloid, or foam or protect the wounds
what do we do with yellow wounds
clean the wound and remove the yellow layer
cover the wounds with hydrogel, foam, or moist gauze with or without debribing enzyme
also consider hydrotherapy with whirl pool or pulselavage
can pressure ulcer be backstages
No, a pressure ulcer cannot be back-staged or reverse staged once it has been staged
it is like a name is cannot be changed
what is the braden scale
a tool used to assess a patient’s risk of developing pressure ulcers, or sores,
what is the norton scale
a tool used to assess a patient’s risk of developing pressure ulcers
what is the gosnell scale
a tool used to assess the risk of developing pressure ulcers in people over 65, especially those living in extended care
what do we do with black wounds
debribe the wound - conservative sharp debridement, or hydrotherapy, enzyme product
for wound with inadqueate blood supply and non-infected do not debribe - keep nice and dry
what is the wagner classification
grading system for diabetic foot ulcers (DFUs) that assesses the depth of the ulcer and the presence of gangrene or osteomyelitis
0-5
when are povidone-iodine solution used
surgical site infection
when znic oxide used
from skin disorders
when is nitrofurazone solution used
for treating burns
how do we decide between selective and non-selective wound care
sometimes 50%
what is Hypertrophic scar:
Hypertrophic scarring
would describe a healed wound with thick
fibrous tissue that remains within the
original wound border
what is a Normal scar look like
Flat and similar to skin color
What is keloid scar
raised scar after an injury has healed.
A keloid is caused by an excess protein (collagen) in the skin during healing.
Lumpy or ridged
grows beyond the boundaries of the initial wound
What are hypertrophic scares
hypertrophic scar is a raised scar that remains confined to the area of the original injury
What is a atrophic scar
flat, sunken indentations in the skin that are caused by a loss of collagen and fat
Acne scars
