Cutaneous Wound Healing

Question 1

how thick is skin?

Answer 1

1.4 to 4 mm

Question 2

epidermis is vascular or avascular?

Answer 2

avascular

Question 3

what kind of tissue is the dermis?

Answer 3

loose connective tissue

Question 4

hyperkeratosis is a thickening of what stratum layer of skin? Who usually has this?

Answer 4

stratum corneum - people with diabetes

Question 5

what is maceration?

Answer 5

excess humidity of tissue - whitish skin (like when bandaid on too long)

Question 6

eschar is what?

Answer 6

black crust from necrotic cutaneous or mucous covering

Question 7

in partial thickness wounds, which cells are doing most of the healing work?

Answer 7

keratinocytes - reepithelialization from edges and areas around glands and hair follicles (epithelial buds)

Question 8

in full-thickness wounds, what is the primary mechanism that healing uses? what kind of tissue is laid down?

Answer 8

wound contraction - scar tissue

Question 9

what are the 4 stages of wound healing?

Answer 9

hemostasis
inflammatory
proliferation
remodelling

Question 10

what type of environment is required for autogenic debridement?

Answer 10

humid

Question 11

what three types of cells are involved in the proliferative stage?

Answer 11

fibroblasts

endo and epi thelial cells

Question 12

when is a wound a chronic one?

Answer 12

4-12wks +

when it takes forever to heal and does not respond well to treatment

Question 13

name four types of chronic wounds

Answer 13

pressure ulcers
venous ulcers
arterial ulcers
neuropathic ulcers

Question 14

how long does one have to be immobile before pressure ulcers start?

Answer 14

only 1-2 hours

Question 15

a stage one pressure sore is unbroken skin, but will do what when a persistently red area is pushed with a finger?

Answer 15

it will not whiten, it will remain red

Question 16

stage two pressure ulcers involve loss of dermis or epidermis or both. What will this look like clinically?

Answer 16

looks like an abrasion, blister, or shallow crater, occasionally with fibrin and looking light red otherwise

Question 17

Stage three goes down to the subcutaneous layer but not beyond underlying fascia. It will look like a deep crater. What else can be present?

Answer 17

sinus tracts and undermining. Necrotic tissue may also be present

Question 18

stage four is all the way down and will have necrosis. what other structures might be affected?

Answer 18

muscle, bone, joint capsule

Question 19

unspecified pressure sores may involve what?

Answer 19

eschar or humid necrotic tissue covering wound bed, so unable to tell stage of ulcer

Question 20

does it hurt to push on pressure sores?

Answer 20

of course it is

Question 21

with venous ulcers, venous distension leads to cells leaking out into tissues where they become brown and swollen. What is this browning called?

Answer 21

hemosiderin

Question 22

what happens after the leaking and browning?

Answer 22

dermatosclerosis, and finally lipodermatosclerosis

Question 23

venous hypertension can come from insufficient valves but also obstruction. What are two ways the veins may become obstructed?

Answer 23

obesity
pregnancy
thrombosis

Question 24

what do venous ulcers usually look like?

Answer 24

shallow weirdly shaped on the bottom 1/3 of the legs. contains moderate exudate

may have swelling, hemosiderin, varicosities and white athrophies surrounding ulcer

Question 25

pain from venous ulcers is worst ___

Answer 25

at night

Question 26

arterial ulcers come from peripheral vascular disease (artherosclerosis, smoking, hypertension, diabetes all predisposing factors). Where is this most likely to affect?

Answer 26

LE - foot/toes/ankle

Question 27

venous ulcers are shallow and wide, what about arterial ulcers? at what level of oxygen might an arterial ulcer be gangrenous?

Answer 27

small and deep - 12 mm Hg

Question 28

how does the wound bed of a arterial ulcer differ from a venous ulcer?

Answer 28

arterial ulcer will have more fibrin than granulation, and less exudate and will be dry. The surrounding area will have cold pale shiny skin with thinkened nails and absent pulse

Question 29

will the pain from arterial ulcers go away with elevation of the leg?

Answer 29

no, it will get worse

Question 30

what disease tends to cause peripheral neuropathy

Answer 30

diabetes

Question 31

sensory neuropathy can lead to what?

Answer 31

repeated/continuous trauma

Question 32

motor neuropathy can lead to what?

Answer 32

muscle atrophy - abnormal pressure points in gait on metatarsal heads, friction and pressure makes callous and possibly hematoma with thinning of fat pad = ulceration, malus performans pedis

Question 33

autonomic neuropathy can lead to what?

Answer 33

altered sweating and vascular responses = dry cracks and hot swollen feet which is perfect for bacteria and fungi

Question 34

where are neuropathic ulcers found the most? What shapes?

Answer 34

bottom of the feet, small and deep

Question 35

what type of wound infection is most common?

Answer 35

topical (ie impetigo)

Question 36

what is the difference between a topical and local infection?

Answer 36

presence of swelling, redness larger than 2cm surrounding wound, surrounding tissue easily damaged as well as granulation tissue

Question 37

what can one use to measure a wound?

Answer 37

cotton swabs and ruler, or use a tracing pad or the clock technique

Question 38

what else is important to assess with peripheral neuropathy?

Answer 38

pressure sensitivity - use wire to see if they can feel at least 8/10 points on feet. skin discolouration and temperature capillary refill (should be 5s or less) pulses raise leg to 30 degrees - toes should stay same colour

Question 39

what does the ankle brachial pressure index check? what other one can you use?

Answer 39

if it's safe to use compression therapy, if enough blood to heal - divide systolic pressure of ankle over arm or toe (TBI)

Question 40

what ABI values indicate arterial insufficiency?

Answer 40

0.8-0.9 = mild insufficiency 0.5-0.7 = moderate, consult vascular surgery less than 0.5 = severe, don't do anything else to heal wound

Question 41

what are three important factors to address in local wound care?

Answer 41

debridement, hydration, inflammation/infection

Question 42

what can be done for treating the cause of venous ulcers? neuropathic?

Answer 42

compression modalities - venous | decrease WB - neuropathic

Question 43

patient centered concerns should involve what?

Answer 43

education about foot hygiene, consults to other professionals

Question 44

when should one not debride a wound?

Answer 44

- insufficient blood blow for healing - dry gangrene - stable eschar on the heels (protects) - problems with coagulation that are not controlled - irradiated tissue - pyoderma gangrenosum - if there is a non-breathable dressing on an infected wound + autolytic debridement - presence of metal composites - wound with vasculitis

Question 45

what is the minimum amount of compression necessary in a preventative drug-store type stocking for helping prevent venous ulcers?

Answer 45

30-40 mm Hg

Question 46

if a patient with venous ulcers has pain or lymphedema, which type of compression bandage are they more likely to prefer?

Answer 46

inelastic, 10-20 mm Hg which create compression when calf muscles contract

Question 47

high compression bandages offer how much pressure?

Answer 47

20-40mm Hg

Question 48

what are some situations where it's good to be precautious about debridement?

Answer 48

- immunosuppressed patient or high risk of infection - very young or old - debridement that keeps macerated tissue moist - enzymes less effective in dry environment - diabetic ulcer - mechanical debridement with pulsed flow more than 15lbs/square inch

Question 49

what are three roles of fibrin

Answer 49

retains fluids protects underlying cells provides substances for coagulation

Question 50

what pressures do mattresses need to be to be curative or preventative?

Answer 50

curative - less than 32mm Hg | preventative - 40-70mm Hg

Question 51

what does the darco shoe do?

Answer 51

decrease wb on toe area during gait

Question 52

what does compression do

Answer 52

improves venous return reduction of edema improved tissue perfusion

Question 53

when should you not use compression?

Answer 53

arterial insufficiency localized infection thrombophlebitis (and 2 wks after) local pressure hypersensitivity pulmonary embolism or DVT congestive heart failure

Question 54

when using an ICP, how should the limb be positioned?

Answer 54

elevated

Question 55

what are the parameters of using an ICP pump?

Answer 55

5-7x/week 30-60 min, with 3:1 on/off compression of 40-60mm Hg - only use up to 0.8 ABI

Question 56

how long should hydrotherapy be used for a) pressure, cellulitis, or burns b) arterial ulcers c) venous and neuropathic ulcers

Answer 56

a) 10-20 minutes (15-20 for pressure ulcers actually) b) 2-10min c) 5-10min

Question 57

when is hydrotherapy a good idea?

Answer 57

when there's lots of crap on the wound | ie bacteria, foreign objects, exudate, topical creams, dead tissue

Question 58

when is hydrotherapy a bad idea?

Answer 58

- wound is already clean or there is a healthy bed of granulation tissue - arterial insufficiency (severe) - DVT - temperature discrimination impairment - severe edema - maceration tissue - hemophilia - unstable physically or mentally - skin cancer - first trimester pregnancy - transmissible infection or infection from certain bacterias that cause incontinence or diarrhea

Question 59

does the wound go into a bath with the dressing on?

Answer 59

yes

Question 60

what should be done during the bath?

Answer 60

AROM