FINAL EXAM - Integumentary System, Burns, Wounds Flashcards
Epidermis - Characteristics (10)
- Prevents dehydration2. Protects from microbes3. Keeps nutrients in the skin4. Responds to stimuli5. Keratin6. Reproductive layer of the skin7. Surrounds hair follicles8. Surrounds sweat and sebaceous glands9. thin10 avascular
The dermis contains (9)
- hair follicles2. nerve endings3. lymph vessels4. blood vessels5. collagen6. elastin7. sweat8. sebaceous glands 9. fibroblasts
fibroblasts in the dermis produce
collagen
Fn’s of the dermis (3)
- provides nutrition2. provides protection3. source of blood flow
Phases of wound healing (5)
- hemostasis2. inflammation3. epithelialization4. proliferation5. maturation
Hemostasis
platelets aggregate, clot formation
inflammation - what occurs and what are the clinical signs
phagocytosis, clinical signs are heat, pain, redness
epithelialization
migration of basal cells; need most environment
proliferation
granulation, contraction
maturation
remodeling, scar formation
Primary (First Intention)
wound borders approximate
Secondary
wound borders are not approximated
Delayed Primary (Third Intention)
Sutured after infection is controlled
Subcutaneous tissue - characteristics (3)
- mostly fat and fascia2. blood vessels that support the dermis and epidermis3. provides cushioning and insulation
What must remain intact in order to get wound to granulate?
periosteum
Tendons are _____ _____ when healthy, but have poor ______
shiny whitevascularity
Acute wound
heals in the expected sequence and time frame
Chronic wound
fails to heal as expected, does not proceed through normal phases of healing
Chronic wound characteristics (4)
- repeated trauma2. abnormal blood flow3. large bacterial load4. local tissue ischemia
Etiology of chronic wounds (3)
- PVD2. DM3. physical immobility
Intrinsic factors of delayed wound healing (5)
- age - geriatric2. chronic diseases3. edema4. poor perfusion - lack of blood flow5. immunosuppression
Extrinsic factors of delayed wound healing (6)
- poor nutrition and hydration2. medications3. necrosis4. bioburden5. infection6. incontinence
Iatrogenic factors of delayed wound healing (4)
- inappropriate wound management2. Desiccation (wound pops open)3. Inadequate offloading4. improper handling of dressings
Factors to consider with wound assessment (7)
- wound classification2. new onset vs recurrence3. wound history - time present, prior treatment interventions4. anatomical location5. Wound appearance6. Appearance of periwound7. sensation
Wound appearance includes (6)
- size2. shape3. tunneling or undermining4. wound bed5. exudate or drainage
Undermining
underneath the opening; NOT down into the wound
Factors looked at when assessing a wound bed (2)
- color2. tissue - granulation or necrotic
Nectrotic wound tissue is either
Eschar or slough
Factors looked at when assessing exudate or drainage (5)
- Amount2. odor3. serous = clear4. sanguineous = bloody5. purulent = thick yellow with green (bacteria)
Appearance of periwound factors that are assessed (3)
- Temperature - Warm=infection; Cold = lack of blood flow2. edema3. rolled edges
Sensation factors that are assessed (3)
- Pain2. temperature3. proprioception
Pressure ulcers
localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction
What amount of time can a pressure ulcer occur?
Can occur in 2 hours
Common locations for Pressure ulcers (8)
- occiput2. scapula3. sacrum4. coccyx5. ischial tuberosity6. greater trochanter7. malleolus8. heel
Risk factors for pressure ulcers (8)
- cognitive decline2. impaired sensation3. advancing age4. contractures5. immobility/inactivity6. inadequate nutrition7. incontinence8. co-morbidities
Pressure Ulcer SDTI description
looks like a bruise, purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. May be painful, firm, mushy, warmer or cooler compared to adjacent tissue. Never Used to Describe a Bruise
Once a SDTI opens what stage is it usually?
III
Stage I pressure ulcer description
intact skin with nonblanchable redness of a localized area usually over a bony prominence. May be painful, firm, soft, warmer or cooler compared to adjacent skin
Stage II pressure ulcer description
Partial thickness, loss of dermis presenting as a shallow open ulcer with a pink wound bed WITHOUT slough. May present as an intact or open serum filled blister. Should not be used to describe skin tears, tape burns, dermatitis, maceration
Stage III pressure ulcer description
Full thickness tissue loss into the subcutaneous layer, fat may be visible but NOT bone, tendon or muscle. Slough may be present but does not cover the depth of the tissue loss. May include undermining and tunneling. Depth varies based on anatomical position
Stage IV pressure ulcer description
full thickness loss WITH exposed bone, tendon, or muscle; slough or eschar, and undermining or tunneling may be present. Osteomyelitis (bone infection) is possible based on the exposed structures
Unstageable pressure ulcer description
Full thickness tissue loss in which the base of the ulcer is cover by slough and/or eschar in the wound bed. True depth cannot be determined until the eschar is removed. NEVER remove a “hard cap”, unless it’s loose and there’s debris around it.
Stage a pressure ulcer by (4)
- ID the deepest part of the wound2. If eschar or slough cover the wound it’s unstageable and assumed it’s either Stage III or IV3. Using staging tools - Pressure ulcer scale for healing (PUSH); Pressure Sore status tool
Arterial Wounds signs and symptoms (6)
- diminished pulse - lack of blood flow to the extremity2. pale, cool, thin or shiny skin3. hair loss4. claudication5. Pain Increase with elevation and exercise (pain when walking)6. dependent position decreases symptoms ( leg hanging off side of bed)
Arterial wound risk factors (6)
- smoking2. htn3. hyperlipidemia4. obesity5. inactivity6. DM
Arterial wound etiology (2)
- acute - blunt trauma2. chronic - arteriosclerosis
Arterial wound - common locations ( 3)
- Anterior tibial region of lower leg2. Dorsum and lateral side of foot3. tips of toes (no blood flow = necrotic tissue)
Arterial wound appearance ( 6)
- punched - out or circular in appearance with measureable depth2. distinct borders with pale dry wound base3. scant to minimal drainage4. significant pain5. periwound reddened6. if edema - localized
Venous wounds - Signs and Symptoms (4)
- skin is dusky, ruddy color2. edema with pitting and possible weeping3. hemosiderin staining and lipodermaterosclerosis4. spider veins
Lipodermaterosclerosis appears
bumpy
hemosiderin staining
proteins leaks causing a brown stain like coloring in the skin
Venous wound risk factors (5)
- Immobility2. pregnancy3. prolonged standing4. smoking5. excessive sodium intake
Etiology of venous wounds
Vascular dysfunction resulting in venous hypertension
Common locations for venous wounds (2)
- pre-tibial area between knee and ankle2. medial malleolus
Appearance of venous wounds (6)
- moderate to heavy exudate2. yellow fibrinous superficial wound base3. wound edges irregular and large4. periwound fibrotic and indurated5. hypergranulation6. warm temperature - lots of fluid
neuropathic (diabetic) ulcers - signs and symptoms (3)
- prolonged inflammation2. impaired vascularization3. impaired immune system
neuropathic ulcer risk factors (7)
- chronic hyperglycemia2. high cholesterol3. elevated blood sugar levels4. smoking5. obesity6. sedentary lifestyle7. family history
Etiology of neuropathic ulcers
lack of protective sensation leads to injury that may go unnoticed; don’t realize they step on something
Neuropathic ulcer common location (3)
- plantar aspect of metatarsal heads2. toes- tips and between toes3. lateral aspect of foot
Neuropathic ulcers are commonly located on the feet because
the patient continually ambulates on bony prominence
Neuropathic ulcer appearance (6)
- bloody exudate2. dry and necrotic3. edema localized4. smaller, but significant depth5. painless due to lack of sensation6. callus formation around periwound
What is a burn and how is it classified?
thermal injury that destroys layers of the skin; classified by size, depth and mechanism
Classification of burn by size (2)
- TBSA - total burn surface area2. rule of 9s (even if only a small area on the chest it’s still 9%)
What are the classifications of burns by depth? (5)
- superficial or first degree2. superficial partial thickness or superficial second degree3. Deep partial thickness or deep second degree4. Full thickness or third degree5. subdermal or fourth degree
Characteristics of Superficial or First degree (3)
- Classic sunburn2. red, dry, painful3. Heals within 3-4 days without scarring
Characteristics of Superficial partial thickness or superficial second degree
- pink to red2. Painful3. blisters - still in tact4. moist5. edema6. heals within 7-10 days minimal scarring
Characteristics of Deep partial thickness or deep second degree (6)
- pale due to disrupted blood flow to the area2. painful3. edema4. decreased sensation5. heals in 3-4 wks - may require grafting6. Heterotrophic scarring
Characteristics of full thickness or third degree
- Dermis has been removed2. black to mottled red/brown to pale, waxy white 3. leather like - tight4. insensate5. epidermis & dermis destroyed6. heals in 4-6wks with scarring 7. need to keep the area stretched to avoid contractures
Characteristics of subdermal or fourth degree
- dry, charry appearance2. muscle or bone exposed3. requires grafting or muscle flap4. hypertrophic scarring - not flat, bumpy/rigid
Classification of burns by mechanism (5)
- thermal (hot liquids/scalding)2. radiation3. chemical (acid, alkali, gas or tar)4. Electrical - pure, arc and flame 5. Other - frostbite
electrical arc burn does not require _____ _____
direct contact
Who is at risk of burns? (7)
- children; ages 1-14yrs old, 2. children that are abused3. men due to work field4. pmh of mental health, dm, neuropathy, and substance abuse5. O2 Dependent (smokers)
Emergent phase 1. time frame 2. focus (6) (MM of burns)
0-72 hrs after injury1. sustain life2. preventing infection3. prepare for surgical closure4. promote healing5. managing pain6. scar formation
Acute phase 1. time frame 2. focus (6) (MM of burns)
72 hours after injury or until wound is closed1. infection control2. grafts3. dressings4. support along with pain management5. splinting6. Social and psychological support
Rehabilitation phase - focus (MM of Burns)
- nutrition2. hydration3. stability4. return to function5. psychological component
Complications of burns (8)
- contractures/deformities2. hypertrophic scarring3. heterotopic ossification4. pain5. heat intolerance6. sun exposure7. pruritus8. psychosocial adjustment
pruritus
itching
cutaneous
pertaining to the skin
lesion
wound, injury, or pathological change in body tissue
systemic
pertaining to a system or the whole body rather than a localized area
therapeutic
pertaining to treating, remediating, or curing a disorder or disease
What accessory organs of the skin are located in the dermis? (3)
- nails2. sweat glands3. sebaceous glands
CF for fat (3)
adip/olip/osteat/o
adipocele
hernia containing fat or fatty tissue
lipocyte
fat cell
steatoma
fatty tumor
CF that mean skin (3)
cutane/odermat/oderm/o
hypodermic
pertaining to below the skin (dermis)
cyan/o
blue
cyanosis
physical sign causing bluish discoloration of the skin and mucous membranes
CF that mean red (3)
erythem/oerythemat/oerythr/o
erythema
redness of the skin caused by congestion of the capillaries in the lower layers of the skin. It occurs with any skin injury, infection, or
erythematous
pertaining to erythema (redness of the skin)
erythrocyte
red blood cell
CF meaning sweat (2)
hidr/o**don’t mistake for h2o=hydr/osudor/o
hidrosis
formation and excretion of sweat
sudoresis
profuse sweating
ichthy/o
dry, scaly
ichthyosis
congenital (meaning present at birth) dermatological (skin) disease that is represented by thick, scaly skin.
kerat/o
horny tissue; hard; cornea
keratosis
Any lesion on the epidermis marked by the presence of circumscribed overgrowths of the horny layer.
melan/o
black
melanoma
malignant tumor that originates in melanocytes and is considered the most dangerous type of skin cancer, which, if not treated early, becomes difficult to cure anc can be fatal
myc/o
fungus