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Wound Care > Exam 1 material > Flashcards

Exam 1 material Flashcards

1
Q

Functions of the skin

PWSMMTSCC

A

Protection

Water Balance

Sebum Production

Metabolism

Melanin

Thermoregulation

Sensation

Communication

Cosmetic

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2
Q

Normal Epidermal Anatomy

A

Stratified epithelium (membranous tissue)

0.06-0.6 mm in thickness

Cellular, but avascular

Composed of several layers of skin

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3
Q

Cells located in the epidermis

KMML

A

Keratinocytes (90%)
Melanocytes
Merkel cells
Langerhans cells

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4
Q

Characteristics of subcutaneous tissue

A

AKA “Hypodermis”

Innermost layer of skin

Provides insulation & cushioning

Stores energy

Adds to skin mobility

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5
Q

Cells located in the epidermis

KMML

A

Keratinocytes (90%)

Melanocytes

Merkel cells

Langerhans cells

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6
Q

Cells located in the dermis

MMLFL

A

Mast cells

Macrophages

Lymphocytes

Fibroblasts

Langerhans cells

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7
Q

What encompasses the reticular layer of the dermis

A

Collagen fibers are more dense here

Increased tensile strength in this area

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8
Q

What is Keratin?

A

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)

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9
Q

Describe the stratum corneum

A

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

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10
Q

What causes damage to the stratum corneum?

A

Mechanically– tape stripping

Chemically–fecal, urinary incontinence

Excessive/insufficient hydration

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11
Q

What is keratin?

A

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)

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12
Q

Describe the stratum lucidium

A

Cells appear clear

Replace shed stratum corneum

Only found in soles, palms, and fingertips

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13
Q

Describe the stratum granulosum

A

“Granular layer”
contain precursors to keratin

1-5 cells thick

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14
Q

Describe the stratum spinosum

A

AKA “Prickle cell layer”

Look like a “little spine”

Contain Langerhans cells (bone marrow derived)

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15
Q

Describe the stratum basale

A

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

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16
Q

What are rete ridges?

A

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

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17
Q

What is the basement membrane zone (BMZ)

A

Semi-permeable membrane regulating transfer of materials between dermis and epidermis

Blister forms with loss of anchor

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18
Q

What is collagen?

A

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

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19
Q

What is elastin?

A

Gives skin elasticity

Secreted by fibroblasts

Do not see scars!

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20
Q

What is subcutaneous tissue composed of?

A

Loose connective tissue

Adipose

Vessels (lymphatic & blood)

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21
Q

Effects of Aging

A

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)

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22
Q

What puts skin “at risk?”

FSMPDIS

A

Friction

Shear

Maceration

Pressure

Drying

Irritants

Stripping of acid mantle

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23
Q

Stages of wound healing

HIPR

A

Hemostasis (< 1 hr)

Inflammation (4-6 days)

Proliferation (4-24 days)

Remodeling (21 days-2 years)

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24
Q

Characteristics of Hemostasis

A

Initiates wound healing cascade

  1. Platelet activation
  2. Activation of clotting cascade
  3. Complement cascade (immune response)
  4. Release of chemicals that promote inflammation

MAIN FUNCTION:
Coagulation and secretion of growth factors

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25
Q

Characteristics of Inflammation

VERN

A

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

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26
Q

What encompasses the vascular events associated with inflammation

A

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

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27
Q

Characteristics of proliferation

A

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”

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28
Q

Cells involved with proliferation

MEFME

A

Macrophages

Endothelial cells
(capillary formation)

Fibroblasts

Myofibroblasts

Epithelial cells
(basal epidermal cells)

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29
Q

Processes occurring during proliferation

DNCWE

A

Degradation of non-viable tissue

Neovascularization

Collagen/extracellular matrix production

Wound contracture

Epithelialization

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30
Q

Characteristics of Remodeling

OOIL

A

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

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31
Q

What is healing by primary intention?

A

Edges brought together and held there by mechanical means

Preferred method of healing

Healing begins within 2-3 days

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32
Q

What are the benefits of primary intention healing?

A

Decreased risk of infection

Decreased time to heal

Minimal scar formation

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33
Q

What are the cut-offs for primary intention separations?

A

< 1 cm = little concern

> 1 cm = dehiscence

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34
Q

What is healing by DELAYED primary intention?

A

Large wounds which are partially closed with retaining sutures/tension sutures

Used if:

  1. Too much strain on periwound skin and subcutaneous tissue otherwise
  2. Concern of infection, drainage needs to take place in order to prevent abscess formation
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35
Q

What is healing my secondary intention?

A

Gradual filling of wound with granulation tissue

Large surface area(s) with retracted edges or when large amounts of tissue has been lost

36
Q

What are the detriments of secondary intention healing?

A

Larger scar

Higher risk of infection

Slower healing time

37
Q

What are systemic factors which affect wound healing?

NOVMDABP

A

Nutrition

Obesity

Vascular status

Medications

Disease/Comorbidities

Age

Behavior

Psychological

38
Q

How does Nutrition affect wound healing?

DPP

A

Malnutrition leads to:

  1. Decreased strength
  2. Poor response to stress
  3. Patients more prone to malnourishment because of catabolic state of wound

Chronic wounds = more proteins and calories in diet

39
Q

How does obesity affect wound healing?

A

High rate of delayed healing, dehiscence, and infection

Adipose tissue vascularity

Increase work put on heart

Edema difficult to assess

Comorbidities likely present

40
Q

How does vascular status affect wound healing?

A

ARTERIAL INSUFFICIENCY:

  1. Decreased oxygen to wound
  2. Chronic non-healing wounds
  3. Increased susceptibility to infection

VENOUS INSUFFICIENCY:

  1. Edema
  2. Fibrin in tissue spaces
  3. High risk for infection
41
Q

How do medications affect wound healing?

SCA

A

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

42
Q

How do diseases affect wound healing?

DVIR

A

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

43
Q

How does age affect wound healing?

CEDDSDD

A

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

44
Q

How do behavioral/psychological conditions affect wound healing?

A

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

45
Q

What local factors affect wound healing?

MDDNSMIB

A

Medication/topicals

Dressings

Desiccation (excess dryness)

Necrotic tissue/eschar

Sensation

Mechanical stress

Infection

Blood supply

46
Q

How do infection and blood supply affect wound healing?

A

INFECTION:

  1. More injury to tissue
  2. Decrease in collagen production and increased cell lysis
  3. Kills cells needed for healing

BLOOD SUPPLY:

  1. Inhibition of fibroblast migration and collagen synthesis
  2. Susceptible to infection and tissue breakdown
47
Q

How do iatrogenic factors affect wound healing?

FIFPFIII

A

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

48
Q

What is included in the HISTORY portion of the examination?

A

Talk to the patient first, look at the wound last!

General history

Past medical history

Social history

49
Q

What is included in the GENERAL HISTORY portion of the examination?

A

Age and sex

Chief complaint

History of present illness

  1. When did wound develop?
  2. How did wound develop?
  3. Current and past treatments

Psychological, cultural, economic

  1. What does the wound mean to the patient?
  2. It the wound a nuisance?
  3. Does it significantly restrict their participation?
  4. Are they even aware that it is there?
50
Q

Why is a PAST MEDICAL HISTORY critical to the examination?

A

Systems review

CARDIOVASCULARLY:

  1. CAD–decreased circulating O2
  2. CHF–edema in (B) LE
  3. PVD & PAD–inadequate vascular & arterial support

RESPIRATORY:

  1. Pneumonia–decreased O2
  2. COPD–decreased O2, potential shear/friction due to HOB elevation
  3. Asthma–steroid meds impair inflammatory phase

ENDOCRINE:
1. Diabetes (HgB A1c)–abnormal glucose levels not compatible with wound healing; polyneuropathy

GI SYSTEM:

  1. GI bleed–decreased blood supply
  2. NG tube feedings–cdif and diarrhea leading to skin breakdown

GENITOURINARY SYSTEM:

  1. Incontinence–skin breakdown, contamination
  2. Kidney failure–dialysis and dietary restrictions can slow wound healing

MUSCULOSKELETAL:

  1. CVA–decrease in mobility, exposure to shear/friction during transfers, decreased sensation
  2. Arthritis–NSAIDS and steroids slow healing

HEMATOLOGIC:

  1. Anemia–insufficient Hg to deliver O2
  2. Fluid/electrolyte imbalance–inadequate nutrients

CANCER:

  1. Radiation–increased risk of skin breakdown
  2. Cytotoxic medications–limits wound healing
51
Q

What is included in the SOCIAL HISTORY portion of the examination?

FOEDPTCD

A

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?)

52
Q

What are 3 risk assessment tools?

PBB

A
  1. PUSH
    - for pressure injuries
    - grade a wound based on length, width, drainage amount, and tissue type
  2. Bates-Jensen Wound Assessment tool
    - Assesses all wound types and monitors healing
  3. Braden Scale
    - Assesses risk of pressure injury formation
53
Q

What are the 3 non-pressure injury wound classifications?

A
  1. Superficial thickness–through epidermis
  2. Partial thickness–epidermis and part of dermis (pink and painful)
  3. Full thickness–epidermis, dermis, and into subcutaneous tissue (perhaps to muscle or bone)
54
Q

What is slough?

A

Necrotic tissue

Hydrated tissue

Yellow, gray, tan, or brown

Soft, thin, fibrinous, stringy, or mucinous

55
Q

What is eschar?

A

Necrotic tissue

Composed of dead skin of subcutaneous cells

Firm, dry, leathery, black or brown

As it is softened, becomes slough

56
Q

What is the difference between a scab and eschar?

A

SCAB:

  • Made up of dried RBCs and serum
  • On top of the skin

ESCHAR:

  • Dead tissue
  • Sits flush with the skin
57
Q

What is epithelial tissue?

A

Deep pink to pearly pink

light purple around edges in full thickness wound

Epithelial islands or bridging

58
Q

What is granulation tissue?

A

Beefy, deep red

Puffy or bubbly appearance

59
Q

What is hypergranulation tissue?

A

Granulation that forms ABOVE surface of surrounding epithelium

Delays epithelialization

60
Q

How is the Ankle Brachial Index (ABI) administered to assess vasculature?

A

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

61
Q

What are the CLINICAL MEASUREMENTS of the wound during objective examination?

CLS(D)DTG

A

Culture

Location

Size and depth

Drainage

Temperature

Girth

62
Q

What should visually be observed?

CVPMSEW

A

Color

Vascularity

Perspiration

Moistness (Mucus membranes)

Scars, stains, calluses (measure and define)

Edema

Wounds or skin lesions (measure and define)

63
Q

What to assess during PALPATION of the wound

TTTMCE

A

Temperature (using dorsum of hand)

Moisture

Texture

Circulation (blanch test of nails for capillary refill)

Edema (pitting vs fluid)

Turgor

64
Q

What is turgor?

A

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

65
Q

What is important about WOUND LOCATION?

A

Important when determining etiology

Bony prominences = likely pressure injury

Bottom of foot = likely neuropathic

Lower leg (gaiter area) = likely venous

Distal extremities = likely arterial

66
Q

What is important about WOUND SHAPE?

A

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

67
Q

What are the 3 methods of measuring wound size?

LTP

A
  1. Linear measurement
  2. Tracings
  3. Photography
68
Q

What are the various components that make up the LINEAR MEASUREMENT?

A

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

69
Q

What is undermining?

A

Tissue destruction underlying intact skin along wound margins

Wound is larger at base than on skin surface

70
Q

What is tunneling?

A

Channels which extend in any direction from wound through subcutaneous tissue

71
Q

What caused tunneling and undermining?

A

Shearing forces

72
Q

How do you measure undermining and tunneling?

A

Start at top of wound (12 o’clock)

Progress clockwise

Measure and document deepest areas

73
Q

What is good about using the LINEAR method?

A

Easy

Inexpensive

Most widely used

Meets requirements for documentation

74
Q

What is bad about using the LINEAR method?

A

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

75
Q

What is the TRACING method of wound measurement?

A

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

76
Q

What is good about using the TRACING method?

A

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

77
Q

What is bad about the TRACING method?

A

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

78
Q

What is the PHOTOGRAPHY method of wound measurement?

A

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

79
Q

What is good about the PHOTOGRAPHY method?

A

Permanent documentation

Relatively easy–less time required

Visualization of various tissue types seen in wound bed

Good reproducibility

80
Q

What is bad about the PHOTOGRAPHY method?

A

Cost

Must ALWAYS be consistent

HIPPA concerns

81
Q

What are the characteristics of SEROUS exudate?

A

Thin and watery plasma; normal in acute inflammatory phase

82
Q

What are the characteristics of SANGUINOUS exudate?

A

Bloody (fresh bleeding); small amount normal in acute inflammatory phase

83
Q

What are the characteristics of SEROSANGUINOUS exudate?

A

Thin, watery, cloudy, yellow, tan

84
Q

What are the characteristics of PURULENT exudate?

A

Thick, opaque, tan, yellow, green or brown, NEVER normal

85
Q

What different COLORS can you have with exudate?

C(A)C(M)P(R)Y(B)G(B)

A

Clear/amber

Cloudy/milky

Pink/red

Yellow/brown

Gray/blue

86
Q

What different CONSISTENCIES can you have with exudate?

Odor?

A

Low viscosity or High viscosity

Clear, non-infected wounds do not have an odor

87
Q

What are the different characteristics of wound edges and margins?

A

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

Wound Care (12 decks)

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