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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
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
26
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
27
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"
28
Cells involved with proliferation MEFME
Macrophages ``` Endothelial cells (capillary formation) ``` Fibroblasts Myofibroblasts Epithelial cells (basal epidermal cells)
29
Processes occurring during proliferation DNCWE
Degradation of non-viable tissue Neovascularization Collagen/extracellular matrix production Wound contracture Epithelialization
30
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
31
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
32
What are the benefits of primary intention healing?
Decreased risk of infection Decreased time to heal Minimal scar formation
33
What are the cut-offs for primary intention separations?
< 1 cm = little concern > 1 cm = dehiscence
34
What is healing by DELAYED primary intention?
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
35
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
36
What are the detriments of secondary intention healing?
Larger scar Higher risk of infection Slower healing time
37
What are systemic factors which affect wound healing? NOVMDABP
Nutrition Obesity Vascular status Medications Disease/Comorbidities Age Behavior Psychological
38
How does Nutrition affect wound healing? DPP
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
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
40
How does vascular status affect wound healing?
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
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
42
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
43
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
44
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
45
What local factors affect wound healing? MDDNSMIB
Medication/topicals Dressings Desiccation (excess dryness) Necrotic tissue/eschar Sensation Mechanical stress Infection Blood supply
46
How do infection and blood supply affect wound healing?
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
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
48
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
49
What is included in the GENERAL HISTORY portion of the examination?
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
Why is a PAST MEDICAL HISTORY critical to the examination?
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
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?)
52
What are 3 risk assessment tools? PBB
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
What are the 3 non-pressure injury wound classifications?
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
What is slough?
Necrotic tissue Hydrated tissue Yellow, gray, tan, or brown Soft, thin, fibrinous, stringy, or mucinous
55
What is eschar?
Necrotic tissue Composed of dead skin of subcutaneous cells Firm, dry, leathery, black or brown As it is softened, becomes slough
56
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
57
What is epithelial tissue?
Deep pink to pearly pink light purple around edges in full thickness wound Epithelial islands or bridging
58
What is granulation tissue?
Beefy, deep red Puffy or bubbly appearance
59
What is hypergranulation tissue?
Granulation that forms ABOVE surface of surrounding epithelium Delays epithelialization
60
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
61
What are the CLINICAL MEASUREMENTS of the wound during objective examination? CLS(D)DTG
Culture Location Size and depth Drainage Temperature Girth
62
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)
63
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
64
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
65
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
66
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
67
What are the 3 methods of measuring wound size? LTP
1. Linear measurement 2. Tracings 3. Photography
68
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
69
What is undermining?
Tissue destruction underlying intact skin along wound margins Wound is larger at base than on skin surface
70
What is tunneling?
Channels which extend in any direction from wound through subcutaneous tissue
71
What caused tunneling and undermining?
Shearing forces
72
How do you measure undermining and tunneling?
Start at top of wound (12 o'clock) Progress clockwise Measure and document deepest areas
73
What is good about using the LINEAR method?
Easy Inexpensive Most widely used Meets requirements for documentation
74
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
75
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
76
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
77
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
78
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
79
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
80
What is bad about the PHOTOGRAPHY method?
Cost Must ALWAYS be consistent HIPPA concerns
81
What are the characteristics of SEROUS exudate?
Thin and watery plasma; normal in acute inflammatory phase
82
What are the characteristics of SANGUINOUS exudate?
Bloody (fresh bleeding); small amount normal in acute inflammatory phase
83
What are the characteristics of SEROSANGUINOUS exudate?
Thin, watery, cloudy, yellow, tan
84
What are the characteristics of PURULENT exudate?
Thick, opaque, tan, yellow, green or brown, NEVER normal
85
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
86
What different CONSISTENCIES can you have with exudate? Odor?
Low viscosity or High viscosity Clear, non-infected wounds do not have an odor
87
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

Wound Care (12 decks)

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