integumentary 1/23 Flashcards
what term for healing? only with what kind of wound?
epithelial tissue proliferates from the wound edges
restores the surface (epidermis) of the skin
epithelialization
partial thickness wound - part of dermis preserved
what term for healing? only with what kind of wound?
beefy, red, vascularized fibroblasts
gradually fills in the hole with a collagen matrix aka scar tissue.
granulation tissue
Full-thickness wounds: penetrate 100% of the dermis, into the underlying hypodermal tissue
what healing phase?
1-4 days peak
Pain, redness, swelling, heat
Inflammatory phase
what healing phase?
4-20 days peak
fibroblasts put down new tissue
Deposition and creating of connective tissue
Proliferation Phase
what healing phase?
21 days to up to 2 years
collagen align itself to be like normal tissue
Strengthening, reorganizing, remodeling collagen fibers
Maturation Phase
what type of wound?
thermal injury by flame, scald, or contact
Burns
what type of wound?
sustained pressure, usually over a bony prominence
Pressure Ulcers
what type of wound?
Poor vascular perfusion, resulting in skin break-down
Vascular Ulcers
what type of wound?
Neuropathy, most commonly from diabetes, resulting in decreased sensation, lack of sweat glands, and poor vascularity
Neuropathic Ulcers
what type of wound? surgical opening (colostomy)
Stomas
what type of wound?
surgical wounds, cuts
Lacerations
what type of wound?
mechanical injury of scrape or rub
Abrasions
what type of burn?
keeps burning until neutralized (acids, bases, caustic agents)
Chemical
what type of burn?
entry, exit, and inside track injuries
multiple injuries
Electrical burns
what type of burn? thermal agent (flame, scald, contact) most common
Thermal burns
what degree burn?
Superficial, redness, hot to touch, no blisters
1st degree
Superficial burn
what degree burn?
Skin is mostly intact, most of the basal layer is intact
Blisters, redness, very painful
2nd degree
Superficial partial thickness
what degree burn? Extends >50% through dermis Yellow/white, some blisters Exudate, eschar Less painful
2nd degree
Deep partial thickness
what degree burn?
White/brown/blackish, painless, dry
Down to subcutaneous, adipose
Must heal via granulation
3rd degree
Full thickness
what healing phase? inflammatory cells (neutrophils, eosinophils, and monocytes)
Inflammatory phase
what healing phase?
- Platelets aggregate around exposed collagen
- Platelets release growth factors (GFs) and cytokines
- “call” a variety of inflammatory cells (neutrophils, eosinophils, and monocytes) to initiate next phase
Hemostasis
what healing phase?
- Proteolytic enzyme notably neutrophils, eosinophils, and macrophages
- Pro-inflammatory cytokines induce synthesis of collagen via fibroblasts
- Secrete growth factors that stimulate migration of fibroblasts, epithelial cells and vascular endothelial cells into the wound
Inflammatory Phase
what healing phase?
- Fibroblast proliferation guide the formation of the ECM extracellular matrix
- Vascular endothelial cell proliferation, promote angiogenesis, leads to granulation
- Keratinocyte migration across newly formed granulation tissue to edge of wound and proliferate, re-epithelization
Proliferative stage
what healing phase?
- Balance between the synthesis of new components of the scar matrix
- Fibroblasts are the major cell type that synthesizes collagen, elastin, and proteoglycans
- Form cross-links in ECM
- Angiogenesis ceases and the density of capillaries in the wound site decreases as the scar matures, so stronger scar
- 75% of its original tensile strength
maturation phase
what to document about wound?
Document wound size
diameter, depth, shape, border, tunneling, drainage
stage of bed sore, decubiti, pressure ulcer?
Nonblancheable erythema
Stage I
stage of bed sore, decubiti, pressure ulcer?
covered thickly in eschar or adherent slough
unstageable
need to remove eschar, slough
stage of bed sore, decubiti, pressure ulcer?
Partial thickness skin loss
Stage II
stage of bed sore, decubiti, pressure ulcer?
Full thickness to the underlying fascia
Stage III
stage of bed sore, decubiti, pressure ulcer?
Full thickness to bone, tendon or muscle
Stage IV
scale for risk for pressure ulcer? max score? good or bad? low risk for pressure ulcer? moderate risk? high risk?
braden scale max score 23, good 15-16 low risk for pressure ulcer 13-14 moderate risk <12 high risk
interventions if high risk for pressure ulcer
- positioning- tilt one way (pillow under hip, leg)
- Offload bony prominences, float the heels
- turning schedule, movement!, bed mobility training
- good nutrition
- air mattress
- wheelchair - always cushion, gel, Roho
- Keep skin clean and dry
how to decrease friction/shearing during transfer?
- Lift, don’t drag
- Keep head of bed low (to avoid sliding)
- Use draw sheet
- Bed mobility training
venous or arterial?
• Punched out, even edges, deeper
• Linked to atherosclerosis, claudication
arterial
venous or arterial?
• Loss of hair
• Cyanotic, pale, ashen
arterial
venous or arterial?
• Linked to diabetes, hypertension, hyperlipidemia, smoking
arterial
venous or arterial?
• Painful
• Minimal drainage
• Absent or decreased pulse, Low ABI
arterial
venous or arterial?
• Rubor of dependency
• ABI
arterial
venous or arterial?
• Large, irregular edges
• Shallow depth, inflamed surrounding skin
• Usually above the malleoli
venous
venous or arterial?
• Edema, indurated, hyperpigmented, hemosiderin staining, red
• Moderate to maximal drainage
venous
venous or arterial?
• Usually minimal pain
Decreased pain with elevation
venous
venous or arterial?
• High ABI >.08
venous
ABI test
best score?
cutoffs?
Ratio of: (highest ankle blood pressure) / (highest brachial pressure)
best 1.0
<0.8 common arterial ulcer, intermittent claudication
>1.2 calcification, arterial hardening/plaques, not reliable reading
venous or arterial wound management?
• Nutrition
• Revascularization
• Control modifiable risk factors
arterial
venous or arterial wound management?
• Moist/optimal wound environment (eg. occlusive dressing, hydrogel)
• Debridement of dead skin
• Protect and prevent with good footwear and regular inspections
arterial
venous or arterial wound management?
• Nutrition
• Compression, Unna Boot (multilayer lower compression gauze bandage with zinc oxide dressing), short stretch
• Control modifiable risk factors
venous
venous or arterial wound management?
• Control exudate (eg. Highly absorptive dressing, multi-layer)
• Debridement
• Protect and prevent with good footwear and regular inspections
venous
what pathology?
inflammation of skin
- common around venous ulcer
- caused by bacteria infection streptococci or staphylococci
- risk factors: increased age, immunosuppression, trauma, presence of wound, venous insufficiency
what next?
what similar?
cellulitis
refer to physician for systemic antibiotics, need to rule out DVT and contact dermatitis
ideal environment for wound healing
Keep the skin dry
Keep wound moist
- Absorb exudate, Impermeable
what type of wound?
- ulcer on the plantar surface of the foot
- often bony prominence, eg. metatarsal head
Diabetic Neuropathic Foot Ulcers
what type of wound? • Decreased blood flow to capillaries • Lack of perspiration/dry, cracking skin • Deterioration of bones/muscles/joints • Callus buildup • Dry cracked callus holds bacteria
Diabetic Neuropathic Foot Ulcers
what type of wound?
- Excessive blood glucose damages capillaries, nerves, and collagen/muscular support
- loss of protective sensation
Diabetic Neuropathic Foot Ulcers
what type of wound?
- foot collapse, builds callus but dries up and breeds bacteria
- common over navicular plantar surface
Diabetic Neuropathic Foot Ulcers
charcot foot - collpasing foot
what scale for grading Diabetic Neuropathic Foot Ulcers?
max score?
low score?
wagner scale
grade good 0 to 5 bad
what wagner scale grade?
- thick calluses, bone deformities, claw toes, prominent metatarsal heads
- no opening yet
- foot at risk
grade 0
what wagner scale grade?
- total destruction of thickness of skin, superficial
- ulcer appears
grade 1
what wagner scale grade?
- penetrates through skin, fat, and ligaments
- down to subcutaneous layer
- does not affect bone
- infected
- deep ulcer
grade 2
what wagner scale grade?
- limited necrosis in toes or foot
- osteomyelitis appears
- abscessed deep ulcers
grade 3
what wagner scale grade?
- limited necrosis in toes or foot
- limited gangrene on digits
grade 4
what wagner scale grade?
- extensive gangrene
- necrosis of complete foot with systemic effects
- need amputation
grade 5
type of debridement?
cover it/seal it in and let body’s own system do the work
Autolytic
type of debridement? Wound scrubbing wet-to-dry, whirlpool, pulsatile lavage, ultrasound
Mechanical
type of debridement?
placement of external enzyme to break up eschar
Enzymatic
type of debridement?
Scalpel, scissors, sharps
selective
type of debridement?
Whirlpool, lavage, wet-to-dry, scrubbing
non-selective
infected or inflamed wound?
- redness is Splotchy, expansive, stripes
- Systemic fever
infected
infected or inflamed wound?
- Strong odor
- Moderate to maximal, serous to purulent exudate
infected
infected or inflamed wound?
- Persistent
- Surrounding tissue indurated/very firm about to pop, increased temp
infected
infected or inflamed wound?
- redness is Well defined borders
- temp increase is localized
inflamed
what non selective debridement
will pull out slough and good tissue, may prevent granulation/epithelial tissue from forming and covering wound
wet to dry
infected or inflamed wound?
- weak odor
- exudate minimal, sanguineous (bloody)
inflamed
infected or inflamed wound?
- Variable pain
- slight to minimal firm induration
inflamed
what dressing?
- very absorptive (2)
- use for mod to heavy exudate
- helps wick away moisture from wound
Calcium Alginate- non-woven, non-adhesive pads, form a moist gel
Hydrofibers (Aquacell)
what dressing?
- absorptive
- area in contact with the wound surface is non-adhesive for easy removal
- min to mod exudate use type with border
- mod to max exudate - need secondary dressing
- use on partial- and full-thickness wounds
foam- foamed polymer solutions with small, open cells capable of holding fluids
what dressing?
- allows you to easily monitor and seal it in
- coated on one side with an adhesive
- no absorption
- impermeable to liquid, water and bacteria but permeable to moisture vapor and atmospheric gases
- epithelializing wound, superficial wound and shallow wound with low exudates,
- primary or secondary dressing
- eg. Tegaderm
transparent film
what dressing?
- water and glycerin
- no absorption
- best for dry wounds to provide moisture
hydrogel
what dressing?
- occlusive bandage, two layers, inner colloidal layer and outer water- impermeable layer.
- some absorption
- contact wound exudate forms gels and provide moist environment
- Available as sheets or thin films, useful on areas that require contouring, such as heels and sacral ulcers.
- not indicated for neuropathic ulcers or highly exudating wounds
- mostly secondary dressing
Hydrocolloid
what dressing?
- little absorption, non-wicking can cause maceration if there is exudate
- highly permeable and relatively non-occlusive
- cotton, polyester or rayon
- used for cleansing, packing and covering a variety of wounds
Gauze
what dressing?
- coated with petrolatum or iodine
- primary dressing promotes moist environment
- non-adherent and require a secondary dressing
- eg. Xeroform
Impregnated Gauze
what type of debridement?
Collagenase Santyl
breaks down eschar
Enzymatic Debridement
what is this for?
Regranex
growth factor for wound healing
what are these for?
• Silvadene, silver (Ag)
• Iodoflex
• Bacitracin, neomycin, polymyxin B (triple antibiotic)
antimicrobials
what is this for?
Negative Pressure Wound Therapy (WoundVac)
highly exudating wounds
what dressing?
- strong hydrophilic gel formation, which limits wound exudates and minimizes bacterial contamination
- suitable for moderate to heavy drainage wounds
- not suggested for dry wound, third degree burn wound and severe wounds with exposed bone.
- require secondary dressings because it could dehydrate the wound which delay healing.
Calcium Alginate
what intervention? increase O2 deliver to whole body help with tissue hypoxemia good for chronic diabetic ulcer expensive
hyperbaric chamber
what modality?
- applied at low intensity with pulsed duty cycle
- enhances all phases of healing
- fibroblast, endothelial, wbc activity stimulated
- enhance strength and elasticity of scar tissue
ultrasound
what modality?
- Enhance healing for chronic ulcers, burns, donor and graft sites
- Monophasic direct current stimulates angiogenesis, epithelial migration, decreased bacteria activity, wound pain, increase oxygen perfusion, tensile strength
HVPC
what dressing?
- Derived from seaweed extraction
- Use for partial or full thickness draining wounds
- Pressure or venous insufficiency ulcers
- Infected wounds with excess drainage
- Requires secondary dressing
- cannot be used on exposed tendon, joint capsule, or bone
alginates
what dressing?
- Encourages autolytic debridement
- moderate absorption
- partial and full thickness wounds with varying levels exudate
- may traumatize periwound
foam
what dressing?
- Infected or non-infected
- can be used for wet to wet, wet to moist, or wet to dry debridement
- increased infection rate compared to occlusive dressing
gauze
what dressing?
- gel forming polymers with strong film or foam adhesive
- use for partial and full thickness wounds
- can be used with granular or necrotic wounds
- moist enviroment for wound healing
- allows autolytic debridement
- cannot be used on infected wounds
hydrocolloids
what dressing?
- made of varying amounts of water and glycerin
- moisture retentive, provides moist environment
- used on superficial and partial thickness wounds (abrasions, blisters, pressure ulcers) with minimal drainage
- allows autolytic debridement
- potential for dressings to dehydrate
- typicall requires secondary dressing
hydrogel
what dressing?
- thin membranes and water-resistant adhesives
- highly elastic able to conform to body contours
- allow easy visual inspection of wound
- superficial or partial thickness wound with minimal drainage (eg. scalds, abrasions, laceration)
- moist environment for healing
- allows autolytic debridement
- cannot be used on infected wounds
- may traumatize periwound
transparent film
dressing with silver will be deactived by
often incorporated in foam dressings, alginate dressings, gauzes and films for antimicrobial activity
saline deactivates silver
must used DI water
ranking non occlusive to most occlusive or vice versa? hydrocolloid hydrogel semipermeable foam semipermeable film impregnated gauze alginate traditional gauze
most occlusive to non occlusive
least permeable to most permeable
ranking least o most moisture retentive or vice versa? alginates semipermeable foam hydrocolloid hydrogels semipermeable films
most to least moisture retentive
burn zone?
area of burn received most severe injury with irreversible cell damage
zone of coagulation
burn zone?
area of less severe injury that possesses reversible damage and surrounds zone of coagulation
zone of stasis
burn zone?
area surrounding zone of stasis that presents with inflammation, but will fully recover without any intervention or permanent damage
zone of hyperemia
compression garments for burns
indicated for what kind of burns?
pressure?
hours per day?
- for burns requiring >14 days to heal
- compression 15-35mmHg to balance collagen synthesis and lysis
- wear 22-23 hours per day until scar matured
desensitization intervention post amputation or burns
- why?
- duration, frequency?
prevent developing hypersensitivity, improve tolerance to variable temperature, touch, pressure, vibration to decrease discomfrt
- 5-10min, 3-4x/day
topical agent for burn? \+ use with or w/o dressing \+ painless, can apply to wound directly, \+ broad spectrum \+ effective against yeast - does not penetrate into eschar
silver sulfadiazine
topical agent for burn? \+ broad spectrum \+ non allergenic \+ dressing application painless - poor penetration - discolors, hard to assess - can cause severe electrolyte imbalance - remove of dressing is painful
silver nitrate
topical agent for burn? \+ broad spectrum \+ antifungal \+ easily removed w water - no effective against pseudomonas - may impair thyroid function - painful application
povidone-iodine
topical agent for burn? \+ broad spectrum \+ penetrates burn eschar \+ may be used with or without occlusive dressings - may cause metabolic acidosis - may compromised respiratory function - may inhibit epithelialization - painful application
mafenide acetate
topical agent for burn? \+ broad spectrum \+ may be covered or left open to air - has caused resistant strains - ototoxic - nephrotoxic
gentamicin
topical agent for burn? \+ bacteriocidal \+ broad spectrum - may lead to overgrowth of fungus and pseudomonas - painful application
nitrofurazone
what pathology?
superficial irritation of skin after exposure to precipitating agent
- common irritants poison ivy, latex, soap, nickel, rubber, topical antibiotics
- symptoms: intense itching, burning, red skin, edema
how to treat?
contact dermatitis
- treat: remove source of irritation, topical steroid
what pathology?
- dark brown or black nonviable tissue becomes hardened
- loss of vascular supply leads to local tissue death
- common in fingers, toes, limbs
- hardened tissue not painful, but significant pain at line of demarcation
- develops slowly
- sometimes leads to self-amputation
- risk factors: DM, atherosclerosis, poor circulation
what can it progress to?
treatment?
dry gangrene
can progress to wet gangrene if infection occurs
treat: serious medication condition, needs immediate medical intervention, pharmacological intervention, surgery, hyperbaric O2 therapy
what pathology?
- bacterial infection in affected tissue, swelling causes sudden stop of blood flow
- can develop after severe burn, frostbite, or injury requiring immediate treatment
- spreads quickly and can be fatal
- presentation: swelling and pain at site of infection, skin turns red to brown to black, blisters with pus, fever, general malaise
treatment?
wet gangrene
treat: immediate medical intervention, surgical debridement, intravenous antibiotic treatment, medication, surgery, hyperbaric O2 therapy
what pathology?
fungal infection affects toenails and nailbed
- present: yellow or brown nail discoloration, hyperkeratosis, hypertrophy of nail
onychomycosis
what pathology?
- chronic autoimmune disease, T cells inflam skin and produce accelerated skin cell growth, cause raised red patching on surface of skin
- may be triggered by skin injury, insufficient /excess sunlight, stress, excessive alcohol, HIV infection, smoking, certain meds
- typically over both knees and elbows
treatment?
- how long does it last?
plaque psoriasis
treat: control symptoms and prevent secondary infection with topical application to systemic meds and phototherapy
- lifelong condition, can be managed and controlled
what pathology?
- superficial fungal infection causes epidermal thickening and scaly skin appearance
- fungus is opportunistic, will rapidly multiply in warm and moist environment
- symptoms: itching, redness, peeling skin between toes, pain, odor, breaks in skin
treatment?
prevention?
tinea pedis, athlete’s foot
treat: medication topical or oral antibiotics
may recur
prevent: dry feet when bathing or swimming, wear sandals in public pools/showers, change socks frequently, proper hygiene, avoid shoes that create moist environment
