Exam 1 material Flashcards
Functions of the skin
PWSMMTSCC
Protection
Water Balance
Sebum Production
Metabolism
Melanin
Thermoregulation
Sensation
Communication
Cosmetic
Normal Epidermal Anatomy
Stratified epithelium (membranous tissue)
0.06-0.6 mm in thickness
Cellular, but avascular
Composed of several layers of skin
Cells located in the epidermis
KMML
Keratinocytes (90%)
Melanocytes
Merkel cells
Langerhans cells
Characteristics of subcutaneous tissue
AKA “Hypodermis”
Innermost layer of skin
Provides insulation & cushioning
Stores energy
Adds to skin mobility
Cells located in the epidermis
KMML
Keratinocytes (90%)
Melanocytes
Merkel cells
Langerhans cells
Cells located in the dermis
MMLFL
Mast cells
Macrophages
Lymphocytes
Fibroblasts
Langerhans cells
What encompasses the reticular layer of the dermis
Collagen fibers are more dense here
Increased tensile strength in this area
What is Keratin?
Tough, flexible, fibrous protein
Resists changes in pH, temperature, and enzymatic digestion
Repels pathogens and prevents excess fluid loss (i.e. function of epidermis)
Types include hard (nails, hair), and soft (cells of stratum corneum)
Describe the stratum corneum
Outermost layer
Dead skin cells filled with keratin
“Brick and mortar” arrangement (Corneocytes & desmosomes)
Provides moisture barrier
Constantly shed due to mechanical and chemical “trauma”
Constantly replaced by the layer below
What causes damage to the stratum corneum?
Mechanically– tape stripping
Chemically–fecal, urinary incontinence
Excessive/insufficient hydration
What is keratin?
Tough, flexible, fibrous protein
Resists changes in pH, temperature, and enzymatic digestion
Repels pathogens and prevents excess fluid loss (i.e. function of epidermis)
Types include hard (nails, hair), and soft (cells of stratum corneum)
Describe the stratum lucidium
Cells appear clear
Replace shed stratum corneum
Only found in soles, palms, and fingertips
Describe the stratum granulosum
“Granular layer”
contain precursors to keratin
1-5 cells thick
Describe the stratum spinosum
AKA “Prickle cell layer”
Look like a “little spine”
Contain Langerhans cells (bone marrow derived)
Describe the stratum basale
AKA “stratum germinativium”
Mitotically active (much proliferation) Cells division happens here
Keratinocytes divide and begin differentiation
Contain stem cells, melanocytes, merkel cells
Contain rete ridges which extend into papillary layer of dermis
What are rete ridges?
Epidermal protrusions that point down into the dermis
Partly responsible for skin integrity
Resistant to shear and friction
Minimal regeneration
Facilitates fluid and cell exchange between layers
Height of protrusions declines with age
What is the basement membrane zone (BMZ)
Semi-permeable membrane regulating transfer of materials between dermis and epidermis
Blister forms with loss of anchor
What is collagen?
Major structural protein
Secreted by dermal fibroblasts
Primarily type 1 in the dermis
Provides tensile strength, mechanical support, and protection of underlying muscle, bones and organs
What is elastin?
Gives skin elasticity
Secreted by fibroblasts
Do not see scars!
What is subcutaneous tissue composed of?
Loose connective tissue
Adipose
Vessels (lymphatic & blood)
Effects of Aging
Decreased dermal thickness (BMZ becomes flat)
Loss of insulating subcutaneous fat
Bony prominences less protected
Thermoregulation affected
Decrease in collagen and elastin
Less recoil leads to wrinkles
Decreased sensation & metabolism
Decrease in sweat glands (skin is dry)
Reduction in blood flow
Poor healing and heat regulation
Decrease in epidermal regeneration and collagen synthesis (poor healing)
Reduction of mast cells
(decrease inflammatory response)
What puts skin “at risk?”
FSMPDIS
Friction
Shear
Maceration
Pressure
Drying
Irritants
Stripping of acid mantle
Stages of wound healing
HIPR
Hemostasis (< 1 hr)
Inflammation (4-6 days)
Proliferation (4-24 days)
Remodeling (21 days-2 years)
Characteristics of Hemostasis
Initiates wound healing cascade
- Platelet activation
- Activation of clotting cascade
- Complement cascade (immune response)
- Release of chemicals that promote inflammation
MAIN FUNCTION:
Coagulation and secretion of growth factors
Characteristics of Inflammation
VERN
Initiates wound healing as the body’s initial response to trauma or injury
Vascular stage
(Hyeremia, 5 signs of inflammation)
Exudate stage serous--clear, yellow purulent--opaque fibrinous--thick hemorrhageic--bleeding
Reparative stage (phagocytosis with true wound healing genesis)
Neo-angiogenesis
MAIN FUNCTION:
REMOVE DEBRIS
What encompasses the vascular events associated with inflammation
Increase vascular permeability and vasodilation
Promote growth and migration of cells for tissue repair
(neutrophils, macrophages, accumulation of lymphocytes)
Rubor, tumor, calor, dolor, loss of function
Characteristics of proliferation
Overlaps with inflammatory phase
(granulation, angiogenesis, contraction, epithelization)
From edges to center of wound
MAIN FUNCTION:
FIBROBLASTS PRODUCE COLLAGEN AND EPITHELIAL TISSUE COVERS THE WOUND
“FILL AND COVER”
Cells involved with proliferation
MEFME
Macrophages
Endothelial cells (capillary formation)
Fibroblasts
Myofibroblasts
Epithelial cells
(basal epidermal cells)
Processes occurring during proliferation
DNCWE
Degradation of non-viable tissue
Neovascularization
Collagen/extracellular matrix production
Wound contracture
Epithelialization
Characteristics of Remodeling
OOIL
Overlaps with proliferative phase
Organization of collagen tissue into more definitive and finite pattern
Increase in tensile strength (scar only 80% as strong)
Lasts between 3 weeks and 2 years
MAIN FUNCTION:
REMODELING OF TISSUE AND INCREASING ITS TENSILE STRENGTH
What is healing by primary intention?
Edges brought together and held there by mechanical means
Preferred method of healing
Healing begins within 2-3 days
What are the benefits of primary intention healing?
Decreased risk of infection
Decreased time to heal
Minimal scar formation
What are the cut-offs for primary intention separations?
< 1 cm = little concern
> 1 cm = dehiscence
What is healing by DELAYED primary intention?
Large wounds which are partially closed with retaining sutures/tension sutures
Used if:
- Too much strain on periwound skin and subcutaneous tissue otherwise
- Concern of infection, drainage needs to take place in order to prevent abscess formation
What is healing my secondary intention?
Gradual filling of wound with granulation tissue
Large surface area(s) with retracted edges or when large amounts of tissue has been lost
What are the detriments of secondary intention healing?
Larger scar
Higher risk of infection
Slower healing time
What are systemic factors which affect wound healing?
NOVMDABP
Nutrition
Obesity
Vascular status
Medications
Disease/Comorbidities
Age
Behavior
Psychological
How does Nutrition affect wound healing?
DPP
Malnutrition leads to:
- Decreased strength
- Poor response to stress
- Patients more prone to malnourishment because of catabolic state of wound
Chronic wounds = more proteins and calories in diet
How does obesity affect wound healing?
High rate of delayed healing, dehiscence, and infection
Adipose tissue vascularity
Increase work put on heart
Edema difficult to assess
Comorbidities likely present
How does vascular status affect wound healing?
ARTERIAL INSUFFICIENCY:
- Decreased oxygen to wound
- Chronic non-healing wounds
- Increased susceptibility to infection
VENOUS INSUFFICIENCY:
- Edema
- Fibrin in tissue spaces
- High risk for infection
How do medications affect wound healing?
SCA
STEROIDS decrease collagen synthesis and suppress immune system; cause vasoconstriction, suppress inflammation and collagen synthesis
CHEMOTHERAPEUTIC AGENTS interfere with cell proliferation, prolong inflammation, and inhibit protein and collagen synthesis
ANTINEOPLSATICS hault fibroblast production
How do diseases affect wound healing?
DVIR
DIABETES accelerates atherosclerosis, is associated with neuropathy, and creates abnormal collagen synthesis
VASCULAR DISEASES decrease blood supply, and also affect oxygen perfusion and tissue oxygenation
IMMUNOCOMPROMISED patients have a higher risk of infection, and these conditions affect phagocytosis
RENAL DYSFUNCTION has a negative affect on granulation and fibroblasts
How does age affect wound healing?
CEDDSDD
Changes in cell activity
Epidermis is thinner and weaker
Delayed inflammatory response
Decreased vascularization and atrophy of dermis
Slow healing
Decrease in sensation and metabolism
Decreased collagen synthesis and fibroblast function
How do behavioral/psychological conditions affect wound healing?
RISK-TAKING BEHAVIORS:
Alcohol abuse and smoking
STRESS:
Increased cortisol levels and slower healing/poorer surgical outcomes
DEPRESSION & ANXIETY:
Impaired immunity and self-neglect, poor appetite
MENTAL ILLNESS:
Impaired judgement
What local factors affect wound healing?
MDDNSMIB
Medication/topicals
Dressings
Desiccation (excess dryness)
Necrotic tissue/eschar
Sensation
Mechanical stress
Infection
Blood supply
How do infection and blood supply affect wound healing?
INFECTION:
- More injury to tissue
- Decrease in collagen production and increased cell lysis
- Kills cells needed for healing
BLOOD SUPPLY:
- Inhibition of fibroblast migration and collagen synthesis
- Susceptible to infection and tissue breakdown
How do iatrogenic factors affect wound healing?
FIFPFIII
Fail to properly diagnose
Fail to provide correct environment for healing
Fail to off-load
Inadequate positioning
Inadequate debridement
Inadequate treatment plan
Inadequate pain control
Inadequate patient education and follow-up
What is included in the HISTORY portion of the examination?
Talk to the patient first, look at the wound last!
General history
Past medical history
Social history
What is included in the GENERAL HISTORY portion of the examination?
Age and sex
Chief complaint
History of present illness
- When did wound develop?
- How did wound develop?
- Current and past treatments
Psychological, cultural, economic
- What does the wound mean to the patient?
- It the wound a nuisance?
- Does it significantly restrict their participation?
- Are they even aware that it is there?
Why is a PAST MEDICAL HISTORY critical to the examination?
Systems review
CARDIOVASCULARLY:
- CAD–decreased circulating O2
- CHF–edema in (B) LE
- PVD & PAD–inadequate vascular & arterial support
RESPIRATORY:
- Pneumonia–decreased O2
- COPD–decreased O2, potential shear/friction due to HOB elevation
- Asthma–steroid meds impair inflammatory phase
ENDOCRINE:
1. Diabetes (HgB A1c)–abnormal glucose levels not compatible with wound healing; polyneuropathy
GI SYSTEM:
- GI bleed–decreased blood supply
- NG tube feedings–cdif and diarrhea leading to skin breakdown
GENITOURINARY SYSTEM:
- Incontinence–skin breakdown, contamination
- Kidney failure–dialysis and dietary restrictions can slow wound healing
MUSCULOSKELETAL:
- CVA–decrease in mobility, exposure to shear/friction during transfers, decreased sensation
- Arthritis–NSAIDS and steroids slow healing
HEMATOLOGIC:
- Anemia–insufficient Hg to deliver O2
- Fluid/electrolyte imbalance–inadequate nutrients
CANCER:
- Radiation–increased risk of skin breakdown
- Cytotoxic medications–limits wound healing
What is included in the SOCIAL HISTORY portion of the examination?
FOEDPTCD
Family history
Occupational history
Environment
Tobacco/alcohol use
Dietary intake
Psychologic/cultural history
Current medications
Description of a usual day (in bed all day? active?)
What are 3 risk assessment tools?
PBB
- PUSH
- for pressure injuries
- grade a wound based on length, width, drainage amount, and tissue type - Bates-Jensen Wound Assessment tool
- Assesses all wound types and monitors healing - Braden Scale
- Assesses risk of pressure injury formation
What are the 3 non-pressure injury wound classifications?
- Superficial thickness–through epidermis
- Partial thickness–epidermis and part of dermis (pink and painful)
- Full thickness–epidermis, dermis, and into subcutaneous tissue (perhaps to muscle or bone)
What is slough?
Necrotic tissue
Hydrated tissue
Yellow, gray, tan, or brown
Soft, thin, fibrinous, stringy, or mucinous
What is eschar?
Necrotic tissue
Composed of dead skin of subcutaneous cells
Firm, dry, leathery, black or brown
As it is softened, becomes slough
What is the difference between a scab and eschar?
SCAB:
- Made up of dried RBCs and serum
- On top of the skin
ESCHAR:
- Dead tissue
- Sits flush with the skin
What is epithelial tissue?
Deep pink to pearly pink
light purple around edges in full thickness wound
Epithelial islands or bridging
What is granulation tissue?
Beefy, deep red
Puffy or bubbly appearance
What is hypergranulation tissue?
Granulation that forms ABOVE surface of surrounding epithelium
Delays epithelialization
How is the Ankle Brachial Index (ABI) administered to assess vasculature?
Take BP with cuff and US device on both forearms, just distal to antecubital fossa as well as on both ankles just above medial malleolus
Take the higher BP of the UE and divide it by the higher BP of the LE to get the ABI
Anything less than 0.9 is considered a sign of arterial disease
What are the CLINICAL MEASUREMENTS of the wound during objective examination?
CLS(D)DTG
Culture
Location
Size and depth
Drainage
Temperature
Girth
What should visually be observed?
CVPMSEW
Color
Vascularity
Perspiration
Moistness (Mucus membranes)
Scars, stains, calluses (measure and define)
Edema
Wounds or skin lesions (measure and define)
What to assess during PALPATION of the wound
TTTMCE
Temperature (using dorsum of hand)
Moisture
Texture
Circulation (blanch test of nails for capillary refill)
Edema (pitting vs fluid)
Turgor
What is turgor?
Indication of extent of dehydration or fluid loss
Gently pinch skin on forearm, sternum, inner thigh, or forehead
- Immediate return = normal
- > 30 sec = poor (moderate to severe dehydration)
- Unable to pinch = severe edema
Reliability decreases with elderly patients–decreases elasticity regardless
What is important about WOUND LOCATION?
Important when determining etiology
Bony prominences = likely pressure injury
Bottom of foot = likely neuropathic
Lower leg (gaiter area) = likely venous
Distal extremities = likely arterial
What is important about WOUND SHAPE?
Important when determining etiology and aggravating factors
Round & Eliptical = likely pressure injury
Jagged edges = likely due to shear or friction
Irregular shape = likely venous
Linear = likely due to trauma or friction
What are the 3 methods of measuring wound size?
LTP
- Linear measurement
- Tracings
- Photography
What are the various components that make up the LINEAR MEASUREMENT?
Measure in cm
Length x width x depth
Consider wound as clock face
- Length = 12-6 (head at 12, feet at 6)
- Width = 3-9 (side to side)
Depth = distance from visible surface to deepest area; cotton tipped applicator probed into deepest portion of wound
Undermining
Tunneling
What is undermining?
Tissue destruction underlying intact skin along wound margins
Wound is larger at base than on skin surface
What is tunneling?
Channels which extend in any direction from wound through subcutaneous tissue
What caused tunneling and undermining?
Shearing forces
How do you measure undermining and tunneling?
Start at top of wound (12 o’clock)
Progress clockwise
Measure and document deepest areas
What is good about using the LINEAR method?
Easy
Inexpensive
Most widely used
Meets requirements for documentation
What is bad about using the LINEAR method?
Poor descriptor of wound
Length and width measurements may not represent the extent of the wound size
Imprecise for large, irregular cavity wounds
Over-estimate size by 10-40%
Need to use careful documentation so that things are consistent
What is the TRACING method of wound measurement?
Provides 2D outline of wound
Place tracing device over wound, trace outer surface of wound on tracing device
WOUND STILL NEEDS TO BE ASSESSED FOR DEPTH, UNDERMINING, AND/OR TUNNELING
What is good about using the TRACING method?
Provides permanent 2D record
Can be placed in patient’s chart
Length and width can be measured from tracing
Can do overlay comparisons to reveal extent of healing
What is bad about the TRACING method?
May damage or contaminate the wound
Pain or discomfort for the patient
More time required for shading in necrotic tissue
WOUND STILL NEEDS TO BE ASSESSED FOR DEPTH, UNDERMINING, AND/OR TUNNELING
What is the PHOTOGRAPHY method of wound measurement?
Need consent from patient
Only take pic of wound with measuring tape placed next to longest part of wound
Wear gloves!
Note camera angle
- Perspective changes depending on the angle
- Must make sure the angle, lighting, distance from wound is same every time
Digital camera software will measure wound
What is good about the PHOTOGRAPHY method?
Permanent documentation
Relatively easy–less time required
Visualization of various tissue types seen in wound bed
Good reproducibility
What is bad about the PHOTOGRAPHY method?
Cost
Must ALWAYS be consistent
HIPPA concerns
What are the characteristics of SEROUS exudate?
Thin and watery plasma; normal in acute inflammatory phase
What are the characteristics of SANGUINOUS exudate?
Bloody (fresh bleeding); small amount normal in acute inflammatory phase
What are the characteristics of SEROSANGUINOUS exudate?
Thin, watery, cloudy, yellow, tan
What are the characteristics of PURULENT exudate?
Thick, opaque, tan, yellow, green or brown, NEVER normal
What different COLORS can you have with exudate?
C(A)C(M)P(R)Y(B)G(B)
Clear/amber
Cloudy/milky
Pink/red
Yellow/brown
Gray/blue
What different CONSISTENCIES can you have with exudate?
Odor?
Low viscosity or High viscosity
Clear, non-infected wounds do not have an odor
What are the different characteristics of wound edges and margins?
Defined vs undefined
Attached or unattached
(unattached = undermining or tunneling)
Fibrotic/firm/hyperkeratootic (callused)
Macerated
Slough
Epibole (rolled or curled under edges; caused by epithelial tissue migrating down into wound instead of across)
Tunneling
Undermining
