Exam I Flashcards
1
Q
what are the main functions of the skin? (5)
A
(1) protection
(2) sensation
(3) maintenance of fluid
(4) immunity
(5) thermoregulation
2
Q
what are the two layers of the skin? are they vascular or avascular?
A
(1) epidermis (superficial layer): avascular
(2) dermis (deep layer): vascular
3
Q
what are the 5 layers of the epidermis from deepest to most superficial?
A
(1) stratum basale
(2) stratum spinosum
(3) stratum granulosum
(4) stratum lucidum
(5) stratum corneum
4
Q
what layer of the epidermis helps withstand friction and shear forces?
A
stratum spinosum
5
Q
what is the thickest layer of the epidermis?
A
stratum spinosum
6
Q
what layer of the epidermis helps prevent water loss?
A
stratum granulosum
7
Q
what layer of the epidermis helps prevent damage from the environment?
A
stratum lucidum
8
Q
what is the role of melanocytes?
A
give skin its pigment
9
Q
what is the role of Langerhans cells?
A
provide an immune response
10
Q
what is the function of Merkel cells?
A
function as mechanoreceptors to detect light touch tactile sensations
11
Q
why is lubrication and hydration of the stratum corneum important?
A
it’s vital to inhibit water loss
12
Q
what are the 2 layers of the dermis?
A
(1) papillary dermis (superficial)
2) reticular dermis (deeper
13
Q
what are the functions of fibroblasts in the dermis? (2)
A
(1) generate collagen (mainly Type 1)
(2) generate elastin
14
Q
what is the function of Meissner’s corpuscles?
A
detect light touch
15
Q
what is the function of Pacinian corpuscles?
A
detect deep pressure and vibration sensations
16
Q
what are the 3 types of skin loss? what is associated with each?
A
(1) erosion: epidermal loss only (1st degree burns; minimal or no bleeding)
(2) partial thickness wounds: loss of epidermis and dermis (2nd degree burns, skin tears)
(3) full thickness wounds: loss of epidermis, dermis, and hypodermis (exposure of bone, tendon; surgical incisions)
17
Q
what are the 4 phases of skin healing?
A
(1) hemostasis
(2) inflammation
(3) proliferation
(4) remodeling
18
Q
what is involved with the hemostasis phase of healing? how long does this phase last?
A
(1) platelet aggregation; stop the bleeding and begin scab formation Clot Form
(2) lasts less than an hour
19
Q
what is involved with the inflammatory phase of healing? how long does this phase last?
A
(1) increased circulation to site and debridement begins; breakdown of dead tissue via phagocytes
(2) 1 hour - 4 days
20
Q
what is involved with the proliferation phase of healing? how long does this phase last?
A
(1) formation of new extracellular matrix; new tissue being laid
(2) 4-12 days
21
Q
what is involved with the remodeling phase of healing?
A
wound closure; collagen replacement (from type III to type I) to increase tensile strength
22
Q
how strong is the scar tissue laid down during the remodeling phase of healing?
A
80% tensile strength of the original skin, which may take up to 2 years to achieve
23
Q
what is recidivism?
A
recurrence of wounds within the injured area due to a decrease in original tensile strength
24
Q
what are the 3 different classifications of wound response?
A
(1) primary intention
(2) secondary intention
(3) delayed primary intention (tertiary)
25
what is associated with a primary intention wound response?
(1) wounds typically seen after surgery
(2) heal uneventfully, without scaring
(3) bacteria and pathogen free
(4) resolves within about 2 weeks
26
what is associated with a delayed primary intention (tertiary) wound response?
(1) suspected debris or pathogens in the wound
(2) increased inflammatory response
(3) resulting granuloma
27
what is associated with a secondary intention wound response?
(1) progress through the stages of wound healing from inflammatory phase, granulation formation and re-epithelialization
(2) myofibrils present for 10-21 days to assist wound closure
28
why is it important for patients to eat protein for healing?
majority of drainage that leaves the wound is comprised of protein and the extracellular matrix is comprised of such proteins that allow for the structural integrity of the skin
29
how long do chronic wounds take to close?
months to years
30
what usually causes chronic wounds? (3)
(1) debris in the wound
(2) pathogen occupants
(3) disease (diabetes, circulatory disorders)
31
what is the most common cause of chronic wounds?
venous insufficient ulcers
32
what are factors that impede healing? (7)
(1) infection
(2) medications
(3) comorbidities
(4) cancer/Radiation
(5) autoimmune disorders
(6) stress
(7) modifiable behaviors/
lack of sleep
33
what are some comorbidities that impede healing? (4)
(1) diabetes
(2) arterial insufficiency
(3) chronic edema
(4) cardiac diseases
34
how does diabetes cause delayed healing?
due to the effects of increased glucose levels on leukocyte function
35
what is a large indicator of healing ability?
cardiac function (the better cardiac function the better ability for the body to heal)
36
how does stress cause delayed healing?
hormones released when stressed such as, epinephrine and NE result in decreased response to injury
37
what are normal WBC levels?
Normal: 4,500 - 11,000 per microliter of blood
38
what are normal hemoglobin levels?
Normal: 12-18 g/dL
39
what are normal HCT levels?
Normal: 36-50%
40
what are normal INR (PT-INR) levels?
Normal: 2.50 seconds
41
what are normal A1C% levels?
Normal: <= 5.7%
42
what are normal average glucose levels?
Normal: <100 mg/dL
43
what does each color indicate using Marion Laboratories Classification System?
(1) red: wound is clean, healing and granulating
(2) yellow: possible infection or necrotic tissue; need cleaning or debridement
(3) black: necrotic tissue; needs cleaning and debridement
44
what scale is the most widely used scale for classifying pressure ulcers?
National Pressure Ulcer Advisory Panel (NPUAP)
45
how does the Wagner Ulcer Grade Classification classify ulcers? what condition is it most commonly used for?
(1) Uses pressure depth and infection using grades from 0-6
| (2) most used for diabetic foot ulcers
46
what does each grade indicate for the Wagner Ulcer Grade Classification?
Grade 0: preulcerative lesions; healed ulcers; bony
deformity
Grade 1: superficial ulcer without subcutaneous
involvement
Grade 2: affects subcutaneous tissue; may
expose bone, tendon, etc.
Grade 3: osteitis, abscess or osteomyelitis
Grade 4: gangrene of digit
Grade 5: gangrene of the foot requiring disarticulation
47
what are the 4 steps a physical therapist should go through with a wound care patient?
(1) General Assessment
(2) Diagnosis
(3) Prognosis and Goals
(4) Re-evaluation
48
what information should you get from a patient when assessing a wound? (5)
(1) wound onset
(2) etiology
(3) signs / symptoms
(4) pain
(5) psychosocial history
49
what are the two main aspects of a would care examination?
(1) Test for factors related to comorbidities
| (2) Wound examination
50
what are the 3 methods used to determine the size of the a wound?
(1) perpendicular method
(2) clock method
(3) tracing / wound photography
51
what is assessed using the clock method of wound measurement?
(1) length
(2) width
(3) depth
52
what is undermining when referring to wound care? how does it typically present?
(1) disruption in the attachment of the skin to underlying structures
(2) often presents as dark/discolored tissue surrounding the periwound
53
what is tunneling when referring to wound care?
a wound that "tunnels" underneath the skin; sometimes there may be two visible openings that are connected underneath the skin (via tunneling)
54
what is eschar tissue?
necrotic tissue; typically black, flat and shinny
55
what is slough tissue?
non-viable subcutaneous tissue; typically soft and yellow as a result of autolytic debridement
56
what is granulation tissue?
viable tissue; usually bright red (composed of matrix and capillaries)
57
what is the difference between viable and non-viable muscle tissue?
(1) viable: red in color, hurts to touch, can contract
| (2) non-viable: grey in color,, non-painful and doesn't contract
58
what is the difference between viable and non-viable bone?
(1) viable: white / tan apperance
| (2) non-viable: black
59
how is a tendon kept viable following a full-thickness wound injury?
must remain moist to prevent desiccation (dryness)
60
what is the difference between viable and non-viable adipose tissue?
(1) viable: shiny globules
| (2) non-viable: dull, yellow
61
what is hypergranulation tissue?
(1) abnormal healing of granulation tissue that overrides the tissue surface
(2) although red, it will cause an inability to heal as the edges will not be able to approximate over the edges of the granulation
62
what are the 6 ways to describe the amount of drainage?
(1) scant: small remnant of drainage of dressing
(2) minimal: 25% of dressing is covered
(3) moderate: 50% is covered
(4) heavy: 100% is covered
(5) copious: multiple layers
(6) strike through: drainage visible through last layer
63
how is serous drainage described?
clear serum
64
how is sanguineous drainage described?
bloody
65
how is serosanguineous drainage described?
mixture of serous and sanguineous (clear and bloody)
66
how is purulent drainage described?
thick, viscous drainage that may smell (pus)
67
how is infected drainage described?
various colors and often has an odor
68
what are some ways the periwound may present?
(1) erythema (redness)
(2) ischemic (pale)
(3) hemosiderin staining (brown / purple discoloration; typical with venous insufficiency)
(4) ecchymosis (bruising)
69
when is the odor of a wound assessed?
AFTER the dressing is removed and the wound is cleaned
70
what is peripheral artery disease characterized by? (3)
(1) arterial insufficiency
(2) claudication
(3) rest pain (more so against gravity)
71
what is claudication?
heavy, painful legs; cramping (usually the calfs) during exertion that dissipates at rest
72
what is one way physical therapists can determine arterial sufficiency?
ABI (ankle brachial index)
73
what are normal levels for ABI? what are borderline PAD values?
(1) normal: 1.0-1.29
| 2
74
what are ABI values ofr mild, moderate, and severe PAD?
(1) mild: 0.7-0.9
(2) mod: 0.4-0.69
(3) severe: <0.4
75
what does an ABI value greater than 1.3 indicate?
heavy vessel calcification
76
how is rubor of dependency test administered and interpreted?
(1) legs elevated to 30 degrees in supine
(2) once pallor is observed, legs are brought to a dependent level
(3) normal: slight pink appearance (return to color within 15 seconds)
(4) abnormal: bright red (baseline takes >30 seconds)
77
why does redness occur during the rubor of dependency test?
in patients with PAD, redness is caused by dilation of arteries in an attempt to reperfuse the extremity, compensating for poor arterial flow
78
how does an arterial insufficiency wound present?
(1) around and small with smooth borders (looks like a hole punch)
(2) lacks granulation and looks pale
(3) distal digits
79
what is the treatment for arterial insufficiency?
```
(1) PRAFO
(P) protection
(R) relief
(AFO) ankle foot orthosis
(2) infrared light
(3) debridement
```
80
how is blood in the venous system pumped back towards the heart? what prevents back flow?
muscle pump; valves prevent back flow
81
what causes venous wounds?
abnormal vessel valves allow for retrograde flow causing pooling in distal LEs
82
what is edema below the lower leg characterized as?
venous insufficiency
83
what is edema extending yo the thigh called?
lymphedema
84
are varicose veins easier to see in standing or supine when assessing a patient?
standing (blood pools because it has to fight against gravity)
85
how do venous insufficiency wounds present?
(1) gaiter area (above malleoli)
(2) insidious
(3) uneven edges, shallow, little eschar
(4) moderate to copious serous (no infection) or purulent (infection) drainage
(5) periwound: increased thickness
86
what is the gold standard treatment for venous insufficiency?
compression
87
what comorbidity would you NOT use compression for when treating a patient for venous insufficiency?
congestive heart failure or PAD (compression for these populations can cause serious complications or DEATH)
88
what are the three types of compression used for treatment of venous insufficiency?
(1) spiral: used for bed bound patients or require minimal compression
(2) figure 8: provides twice as much compression as spiral; used for patients use regularly walk and have good ABI
(3) 4 layer: includes 4 layers which are cotton padding, non-elastic, long stretch (figure 8), and self adhering bandage (listed from deepest to most superficial)
89
what is the proper name for a pressure sore?
pressure injury
90
what are the 4 mechanisms that are thought to cause pressure injuries?
(1) ischemia: compression of capillaries
(2) impaired lymphatic flow: increased metabolic waste
(3) reperfusion: inflammatory response
(4) deformation of tissues
91
how long does it take for local hyperemia to occur at the location of a pressure injury?
30 minutes
92
how long does it take for ischemia to occur at the location of a pressure injury?
2-6 hours of continuous pressure
93
how long does it take for necrosis to occur at the location of a pressure injury?
6 hours of continuous pressure
94
how long does it take for ulceration to occur at the location of a pressure injury?
2 weeks after necrosis
95
how do Stage 1 pressure injures present?
non-blanchable erythema of intact skin
96
how do Stage 2 pressure injures present?
partial thickness loss with exposed dermis
97
how do Stage 3 pressure injures present?
full thickness skin loss; bone / tendon / muscle not exposed (may include necrotic tissue)
98
how do Stage 4 pressure injures present?
full thickness skin and tissue loss; exposed bone / muscle / tendon
99
how do unstageable pressure injures present?
obscured full-thickness skin and tissue loss; base covered in slough or eschar (until wound is debrided, the full depth can't be ascertained)
100
how do suspected deep tissue injuries present?
persistent non-blanchable, deep red, maroon, or purple coloration
101
necrotic tissue is present within a pressure wound what level is it automatically classified as?
stage 3 (at least)
102
what are risk factors for pressure injuries?
(1) immobility
(2) inactivity
(3) sensory loss
(4) shear / friction forces
103
what are the 6 variables of the Braden scale that are assessed? what is the max score?
(1) sensory perception
(2) moisture
(3) activity
(4) mobility
(5) nutrition
(6) friction and shear
Max Score: 23 (this being lowest risk for pressure sore)
104
what is considered low risk for pressure injuries according to the Norton scale?
17-20 out of 20
105
what are interventions we can implement as PTs to treat or prevent pressure injuries?
(1) pressure relief - PRAFO's
(2) pressure redistribution support systems (roho cushions, air mattresses)
(3) care for moisture prone areas (barrier creams)
(4) reduce friction / shearing forces
106
what is debridement?
removal of dead, damaged, or devitalized tissue
107
what is the purpose of debridement?
(1) encourages wound healing process
(2) reduces chronic inflammation by removing necrotic tissue
(3) promotes keratinocyte growth
108
what are some things to consider before debriding a wound?
(1) history taking (lab values, medications, INR level, pain level)
(2) ABI value (vascular insufficiency would require a referral)
109
what are contraindications to debridement?
(1) ABI < 0.4
(2) dry gangrene or dry ischemic wounds
(3) elevated temp
(4) cellulitis (or other bacterial infections)
(5) visible exposure to bone, tendon
(6) prosthetic devices
(7) evidence of extreme undermining
110
when should you debride stable eschar?
NEVER
111
how is a wound debrided using biological agents?
maggot / leech therapy
(1) maggots only debride necrotic tissue and stay in the wound for 1-4 days
(2) leech therapy brings blood to the area
112
what is autolytic debridement?
using the body's natural healing mechanisms to debride non-viable tissue
113
what is enzymatic debridement?
using chemicals to remove non-viable tissue
114
what is mechanical debridement?
using outside force or energy to dislodge the non-viable tissue
115
what is sharp debridement?
using instruments to remove non-viable tissue
116
what is involved with autolytic debridement?
(1) cleaning wound
(2) maintain moist environment
(3) cross hatch eschar
(4) cover with dressing to promote healing
117
what are advantages and disadvantages of autolytic debridement?
```
Advantages
(1) rapid improvement
(2) selective (doesn't debride health tissue)
(3) can combine w/ other debridement types
Disadvantages
(1) caregiver education
(2) slower than sharp
(3) increased risk for infection
```
118
what is involved with enzymatic debridement?
(1) obtain physician's orders
(2) cleanse wound
(3) apply enzyme to non-viable tissue
(4) cover with dressing
(5) administer 1-2x / day
119
what are advantages and disadvantages of enzymatic debridement?
```
Advantages
(1) selective
(2) can combine w/ other debridement types
Disadvantages
(1) costly
(2) slow to notice improvement
```
120
what is the main enzymatic agent for debridement?
Santyl
121
what are the gold standard parameters for using pulsatile lavage debridement?
35-50 cc syringe
19 gauge catheter
4-9 PSI
**Avoid PSI >15**
122
what are advantages and disadvantages of mechanical debridement?
```
Advantages
(1) used in a variety of settings
(2) decreased bacteria
Disadvantages
(1) painful
(2) non-selective
(3) may cause maceration
```
123
what is involved with sharp debridement?
(1) pre-medicate
(2) assembly agents to stop excess bleeding
(3) cleanse wound
(4) use scalpel blades to remove non-viable tissue
124
what are advantages and disadvantages of sharp debridement?
```
Advantages
(1) selective
(2) speed
Disadvantages
(1) painful
(2) requires experience
(3) increased potential for complications
```
125
how long should pressure be applied to a wound with excess bleeding before using topic agents?
5-10 minutes
126
how can corticosteroids affect healing? what can be used to mediate the effects of steroids?
(1) steroids cause a delay in all phases of healing
| (2) vitamin A
127
how can NSAIDs affect wound healing? (2)
(1) decreased platelet aggregation
| (2) decreased tensile strength of tissues
128
what is a granuloma?
a mass of granulation tissue, typically produced in response to infection, inflammation, or debris
129
what type of bacterial gives off a characteristically sweet odor?
pseudomonas
130
what type of odor does gangrene typically give off?
very foul odor
131
what is the Braden scale used to predict?
pressure sore risk
