Integumentary Flashcards
Indolent =
a long-standing, often painless wound that is very slow to heal and is a characteristic of a venous insufficiency ulcer
induration=
the hardening of the skin around an ulcer, often occurring with pressure sores or venous insufficiency ulcers
maceration=
the softening and deterioration of the skin or wound as a result of moisture
purulent=
indicates a wound that contains pus and is infected
Functions of the skin
1- protect underlying body structures against injury or invasion
2-insulation of body
3- maintenance of homeostasis: fluid balance, regulation of body temp
4- assists in metabolism:
- vitamin D production
- aids in elimination of metabolic waste (era and salt are excreted in sweat)
5- attachment of muscles (erector pili, frontalis)
6- receptors in dermis give rise to cutaneous sensations
layers of the skin
Epidermis: outer layer
-no bood vessels
Dermis: inner layer
- composed primarily of collagen and elastin fibrous CT
- contains blood vessels, lymphatics, nerve endings, sebaceous and sweat glands
Subcutaneous tissues (hypodermis): underneath dermis
- “superficial fascia or subcutaneous fat”
- consists of loose connective and fat tissues
- provides insulation, support, and cushion for skin; stores energy
- muscles and deep fascia lie underneath subcutaneous layer
appendages of the skin
Hair
- terminal hair
- vellus hair
Nails
Sebaceous glands
Sweat glands
sebaceous glands
exocrine glands that secrete fatty substance (sebum) through hair follicles
found on all skin surfaces except palms and soles
sebum lubricates skin, defends against bacteria and fungus
sweat glands
Eccrine glands:
- widely distributed, open on skin
- help control body temp
Apocrine glands:
- found in axillary and genital areas
- open into hair follicles
- stimulated by emotional stress
Dermatitis
“eczema”
inflammation; causes itching, redness, skin lesions
Causes:
- allergic or contact dermatitis (poison ivy, harsh soaps, chemicals, adhesive tapes)
- Actinic: photosensitivity, reaction to sunlight, UV
- Atopic: unknown, associated with allergic, hereditary or psychological disorders
Stages:
- Acute: red, oozing, crusting rash; extensive erosions, exudate, pruritic vesicles
- Subacute: erythematous skin, scaling, scattered plaques
- Chronic: thickened skin, increased skin marking secondary to scratching; fibrotic papillose, and nodules; post inflammatory pigmentation changes. Course can be relapsing
Precautions:
- some modalities
- avoid alcohol
Medical mgmt:
-topical or systemic therapy (corticosteroids, immunosuppressants, antihistamines)
Bacterial infections
enter through portals in the skin (abrasions or puncture wounds)
1- impetigo
2-cellulitis
3-abscess
Impetigo
superficial bacterial skin infection caused by staphylococci or streptococci
associated with inflammation, small pus filled vesicles, itching
contagious; common in children and elderly
Cellulitis
suppurative inflammation of cellular or CT in or close to the skin
tends to be poorly defined and widespread
streptococcal or staphylococcal infection common; can be contagious
skin is hot, red and edematous
management:
- antibiotics
- elevation
- cool, wet dressings
if untreated: lymphangitis, gangrene, abscess and sepsis can occur
increased risk: elderly, diabetes, wounds, malnutrition, or on steroid therapy
Abscess
a cavity containing pus and surrounded by inflamed tissue
result of a localized infection
commonly a staphylococcal infection
healing typically facilitated by draining or incising the abscess
List of Vial infections
Herpes 1 (simplex)
Herpes 2
Herpes zoster (shingles)
Warts
Herpes 1
herpes simplex
itching and soreness, followed by vesicular eruption of the skin on the face or mouth
a cold sore or fever blister
Herpes 2
common cause of vesicular genital eruption
spread by sexual contact
in newborns may cause meningoencephalitis; may be fatal
Herpes zoster
“shingles”
caused by varicella-zoster (chickenpox); reactivation of virus lying dormant in cerebral ganglia or ganglia of posterior nerve roots
pain and tingling affecting spinal or cranial nerve dermatome
- progresses to red papules along distribution of infected nerve
- red papillose progress to vesicles develop along a dermatome
accompanied by fever, chills, malaise, GI disturbances
ocular complications with CN III: eye pain, corneal damage
loss of vision with CN V
Management: no curative agent
- antiviral drugs slow progression
- symptomatic tx for itching and pain (systemic corticosteroids
contagious to those who haven’t have chickenpox
**heat/US contraindicated: can increase severity
warts
common, benign infection by HPVs
transmission through direct contact
Fungal infections
Ringworm (tinea corporis)
- fungal infection of hair, skin, nails
- forms ring shaped patches with vesicles or scales
- itchy; through direct contact
- treated with topical or oral anti fungal drugs
Athlete’s foot
- fungal infection of foot, typically b/w toes
- causes erythema, inflammation, pruritus, itching, and pain
- treated with anti fungal creams
- can progress to bacterial infections, cellulitis if untreated
transmission: person-person or animal to person
- standard precautions
Parasitic infections
caused by insect and animal contacts
transmission: person to person or sex
- standard precautions
1- Scabies (mites)
- burrow into skin, causing inflammation, itching, and possibly pruritus
- treated with scabicide
2- Lice (pediculosis)
- parasite that can affect head, body, genitals, with bite marks, redness and nits
- tx: special soap/shampoo
List of Immune disorders of the skin
1- psoriasis
2-lupus erythematosus
3-scleroderma
4-polymyositis (PM)
psorasis
chronic autoimmune disease of skin characterized by erythematous plaques covered with a silvery scale
-common on ears, scalp, knees, elbows and genitalia
S&S: itching and pain from dry, cracked lesions
variable course
may be associated with psoriatic arthritis, joint pain, particularly in small joints
etiology: hereditary, associated immune disorders, certain drugs
precipitating factors:
- trauma
- infection
- pregnancy and endocrine changes
- cold weather
- smoking
- anxiety/stress
mgmt: no cure
- corticosteroids
- occlusive oitnments
- immunosuppressive drugs: methotrexate
PT:
long wave UV light
-combo UV light with oral photosensitizing drugs (psoralen)
lupus erythematosus
chronic, progressive autoimmune inflammatory disorder of CT
-characteristic red rash with raised, red, scaly plaques
Discoid lupus (DLE): affects only skin
- flare ups with sun exposure
- lesions can resolve or cause atrophy, permanent scarring, hypo or hyper pigmentation
Systemic lupus (SLE): chronic, systemic inflammatory disorder affecting pultiple organ systems, including skin, joints, kidneys, heart, NS, mucous membranes
- can be fatal
- common in young women
- Symptoms: fever, malaise, butterfly rash across bridge of nose, skin lesions, chronic fatigue, arthralgia, arthritis, skin rashes, photosensitivity, anemia, hair loss, Raynauds
management: no cure
- topical tx of skin lesions (corticosteroids)
- observe for side effects of corticosteroids
- edema, weight gain, acne, HTN, bruising, purplish stretch marks
- long term associated with increased susceptibility to infection (immunosuppressed), osteoporosis, myopathy, tendon rupture, diabetes, gastric irritation, low potassium
long term risks with corticosteroids
immunosuppression osteoporosis myopathy tendon rupture diabetes gastric irritation low potassium
scleroderma
chronic, autoimmune diffuse disease of CT causing fibrosis of skin, joints, blood vessels and internal organs (GI tracts, lungs, heart, kidneys)
-usually accompanied with Raynauds
skin is taut, firm, edematous, firmly bound to subcutaneous tissues
limited systemic sclerosis/sclerderma:
- symmetrical skin involvement of distal extremities and face
- slow progression of skin changes
- late visceral and pulmonary HTN involvement
- associated with CREST syndrome
Diffuse systemic sclerosis disease/scleroderma:
- symmetrical widespread skin involvement of distal and primal extremities, face, trunk
- rapid progression of skin changes with early appearance of visceral involvement
- important internal organs frequently involved: kidneys, heart and lungs
Mgmt: no specific therapy
-corticosteroids, vasodilators, analgesics, immunosuppressive
PT: slow down development of contracture and deformity
Precautions with sclerosed skin:
- sensitive to pressure
- acute HTN may occur
- stress regular BP checks and VC monitoring
- pulmonary HTN can lead to R sided heart failure in severe cases
CREST syndrome
Calcinosis Raynaud's Esophageal dysfunction Sclerodactyly Telangiectasias
polymyositis
a disease of CT characterized by edema, inflammation and degeneration of the muscles
-dermatitis with some forms
affects primarily proximal muscles: shoulder and pelvic girdle, neck, pharynx; symmetrical distribution
etiology: unknown; autoimmune reaction affecting muscle tissue with degeneration and regeneration, fiber atrophy; inflammatory infiltrates
rapid, severe onset: may require ventilatory assistance, tube feeding
cardiac involvement; may be fatal
mgmt: corticosteroids and immunosuppressants
precautions:
- additional muscle fiber damage with too much exercise
- contractures and pressure ulcers from inactivity
PT:
- fatigue mgmt, conservation of energy
- exercise (aerobic and resistance exercise at low levels)
- positioning to prevent contractures and ulcers
benign skin tumors
seborrheic keratosis
-removed with cryotherapy
actinic keratosis: flat, round, irregular
-precancerous- can lead to squamous cell carcinoma
common mole/benign nevus
-proliferation of melanocytes
Malignant skin tumors
basal cell carcinoma
squamous cell carcinoma
malignant melanoma
kaposi’s sarcoma
basal cell carcinoma
slow growing, epithelial basal cell tumor
characterized by raised patch with ivory appearance or as a reddened area of eczema
rolled border with indented center or presents as a thickened area of skin
rarely metastasizes, common on face in fair skinned
associated mostly with prolonged sun exposure
squamous cell carcinoma
poor defined margins
presents as a flat, red area, ulcer or nodule
grows more quickly, common on sun exposed areas, face and neck, back of hand
higher risk to metastasize
malignant melanoma
tumor arising from melanocytes
clinical manifestations: ABCDEs -Asymmetry -Border -Color -Diameter >6mm Elevation/Evolution
contusion
“bruise”
skin is not broken
pain, swelling, discoloration
immediate cold pack can limit effects
eccymosis
bluish discoloration of skin caused by extravasation of blood into the subcutaneous tissues
result of trauma to underlying blood vessels or fragile vessel walls
petechiae
tiny red/purple hemorrhagic spots on the skin
abrasion
scraping away of skin
laceration
an irregular tear of the skin
torn, jagged wound
pruritus
itching
common in diabetes, drug hypersensitivity, hyperthyroidism
turgur
lift skin on back of hands
indicates hydration status sss
examination of skin
pruritis uticaria rash xeroderma edema changes in nails changes in skin changes in skin color changes in skin temp hidrosis changes in hair presence of lesions, unusual growths
uticaria
smooth, red, elevated patches of skin
“hives”
indicative of an allergic response to drugs or infection
xeroderma
excessive dryness of skin with shedding of epithelium
can indicate deficiency of thyroid function, diabetes
edema can indicate:
can indicate anemia, venous or lymphatic obstruction, inflammation; cardiac, circulatory or renal decompensation
determine activities/postures that aggravate or relieve
palpation, volume and girth measures
change in nails
clubbing: thickened and rounded nail end with spongy proximal fold
- indicates Crohn’s or cardiac/cyanosis, lung (cancer, chronic hypoxia), ulcerative colitis, biliary cirrhosis, neoplasm, GI involvement
- Schamroth’s window test- loss of diamond space
white spots seen with trauma to nails
splinter hemorrhages: small areas of bleeding under nail bets
-possible cardiac or renal signs
changes in skin color
cherry red: palmar erythema could indicate liver or renal issues
cyanosis: slightly blue/gray
- indicates lack of oxygen– CHF, advanced lung disease, congenital heart disease, venous obstruction
pallor- pale
- indicate anemia, internal hemorrhage, lack of sun
- temporary pallor seen with arterial insufficiency and syncope, chills, shock, vasomotor instability or nervousness
yellow/jaundice: liver disease
liver spots: brown/yellow spots may be due to aging, uterine and liver malignancies, pregnancy
brown: pigmentation or venous insufficiency (hemosiderinosis)
changes in skin temperature
abnormal heat:
- febrile condition
- hyperthyroidism
- mental excitement
- excessive salt intake
abnormal cold:
-poor circulation or obstruction (vasomotor spasm, thrombosis, hypothyroidism)
hidrosis
hyperhydrosis (moist skin)- increased perspiration
- fevers
- pneomonic crisis
- drugs, hot drinks, exercise
hypohydrosis- dry skin
- dehydration
- ichthyosis
- hypothyroidism
- seen in late DM
cold sweats
- fear, anxiety, depression
- AIDS
Burn wound zones
zone of hyperemia:
-minimal cell injury; cells should recover
zone of stasis:
- cells are injured
- may die without specialized treatment usually within 24-48 hours
zone of coagulation:
- cells are irreversibly injured
- cell death occurs
Burn would classification
1st degree: Epidermal burn
2nd degree:
- superficial partial thickness
- deep partial thickness
3rd degree: full thickness
4th degree: subdermal burn
Classification by percentage of body area burned:
- Critical: 10% 3rd degree and >30% 2nd deg; complications common
- Moderate:
1st degree burn
“epidermal burn”
Characteristics:
- damage to epidermis only
- pink/red appearance
- no blistering; dry surface
- tenderness, delayed pain
Healing/scarring
- spontaneous healing in 3-7 days
- no scarring
2nd degree burn: superficial partial thickness burn
Characteristics:
- epidermis and upper layers of dermis damaged
- bright pink/red appearance
- blanching with brisk capillary refill
- blisters, moist surface, weeping
- moderate edema
- painful, sensitive to touch, temp changes
Healing/scarring:
- spontaneous healing; typically 7-21 days
- min or no scarring; discoloration
2nd degree burn: deep partial thickness burn
Characteristics:
- severe damage to epidermis and dermis with injury to nerve endings, hair follicles and sweat glands
- mixed red or waxy white appearance
- blanching with slow capillary refill
- broken blisters, wet surface
- marked edema
- sensitive to pressure but insensitive to light touch or soft pin prick (not all nerve endings are destroyed
Healing/scarring
-slow healing and occurs through scar formation and reepithelialization
-excessive scarring w/out preventative tx
3-5 weeks
3rd degree:
“full thickness burns”
Characteristics:
- complete destruction of epidermis, dermis and subcutaneous tissues; may extend into muscle
- white (ischemic), charred, tan or black appearance
- no blanching; poor distal circulation
- parchment-like, dry leathery surface; depressed area
- little pain; nerve endings destroyed (severe pain in surrounding tissues)
Healing/scarring
- removal of eschar and skin grafting are necessary due to destruction of dermal and epidermal tissue
- risk of infection increased
- hypertrophic scarring and wound contracture are likely to develop without preventative measures
- keloid scarring (scar beyond boundaries of original burn can occur)
4th degree burn
subcutaneous burn
Characteristics:
- complete destruction of epidermis, dermis, with involvement of subcutaneous tissues and muscle
- charred appearance
- destruction of vascular system, may lead to additional necrosis
- from electrical burns; prolonged contact with flame
- additional complications likely with electrical burns: ventricular fibrillation, acute kidney damage, SC damage
Healing/scarring:
- heals with skin grafting and scarring
- requires extensive surgery; amputation may be necessary
complications of burn injuries
infection: leading cause of death; gangrene may develop
- the destruction of defense mechanisms against bacteria
shock
pulmonary complications
- smoke inhalation –>pulmonary edema and airway obstruction
- restrictive lung disease from trunk burns
- death due to pneumonia
metabolic complications
-increased metabolic and catabolic activity results in weight loss, negative nitrogen balance and decreased energy
cardiac and circulatory complications:
-fluid and plasma loss results in decreased CO
integumentary scars and contractures
epithelial healing:
retention of viable cells allows for epithelialization to occur
-cells grow, proliferate and migrate to cover the wound
PT should be concerned with protecting and moisturizing the epithelial cells to promote wound healing
-loss of sebaceous glands
dermal healing
results in scar formation (injured tissue is replaced by CT)
scars are initially red or purple, later white
healing phases
1- inflammation phase:
- redness, edema, warmth, pain, decreased ROM
- 3-5 days
2- Proliferation phase
- granulation or fibroblastic phase
- 4 primary events: angiogenesis, granulaton formation, wound contraction, epithelialization
- begins 2-3 days after and lasts several weeks
- characterized by wound contracture, granulation tissue filling the defect and epithelial cells migrating from the wound margins
3- Maturation phase:
- begins 2-4 weeks after injury, remodeling lasts up to 2 years
- normal mature scar is soft, white and flat
- 6-12 weeks scar is immature (bright pink)
- scarring- hypertrophic, keloid, hypotrophic
Hypertrophic scarring
raised scar that stays within the boundaries of the burn wound is characteristically red, raised, firm
collagen production rate exceeds breakdown
Keloid scarring
raised scar that extends beyond the boundaries of the original burn wound and is red, raised firm
-more common in young women and those with dark skin
collagen production exceeds breakdown
Hypotrophic scarring
flat and depressed below the surrounding skin
Burn management:
emergency:
- immersion in cold water
- cover with sterile bandage, no ointments/creams
Medical management: 1:asepsis and wound care -remove charred clothing -wound cleanse -topical meds (antibacterials) -dressings 2- maintain respiratory funciton 3- monitor ABG, VS, GI function 4- pian relief 5- prevention/control infection 6- fluid replacement therapy 7- surgery
topical meds for burns
ointments:
- bacitracin
- polymyxin B
- neomyxin
Silver sulfadiazine
sulfamylon- penetrates through eschar
dressings for burns
Functions: prevent bacterial contamination prevent fluid loss protect wound may additionally limit ROM
Dressings: silver impregnated hydrogels petroleum-impregnated gauze
debridement
used to remove necrotic tissue, prevent infection and promote revascularization and/or reepithelialization
selective: scalpel, autolytic dressings, etc
non-selective: hydrotherapy and dressings (wet-wet, wet-dry, dry-dry) in which necrotic tissue clings to the dressing when removed
burn surgery
primary reason: removal of eschar
- early excision is easier on patient
- promotes more rapid healing
- reduces infection and scarring
- more economical than repeated debridement
- prevents tourniquet effects
Skin grafts
types?
used to close a burn wound at the time of primary excision
Autograft: made from patient’s own skin
Allograft/homograft: skin taken from a cadaver
Xenograft/heterograft: skin from another species (usually pig)
Split thickness: epidermis and upper layers of dermis from donor
Full thickness: both epidermis and dermis from donor
**discontinue exercise for 3-5 days to allow grafts to heal
compression therapy for burns
following grafting, the injured part is rested and pressure dressings are applied to reduce graft separation
pressure garments (custom) are used to help prevent or minimize hypertrophic or keloid scarring
PT for burns
prevent scar contracture
**AROM 2 hrs w/in 24 hours of admission –>PROM
maintain ROM
maintain/improve muscular strength
maintain/improve endurance
return to normal function and ADLs
immersion in hydrotherapy tank
-contraindicated with severe cardiovascular, renal or pulmonary restrictions
debridement
-autolytic dressings help remove eschar
exercises to promote deep breathing and chest expansion
ambulation to prevent pneumonia
edema control
massage to reduce scar formation- deep friction
Splinting and positioning burn wounds
1: Anterior neck: flexion contracture
- position hyperextsion with a firm cervical brace
2-Shoulder: adduction and IR contracture
-position ABD and ER using airplane splint
3- Elbow: flexion and pronation contracture
-position in extension and supination splint
4- Hand:
- claw hand contracture: position in wrist ext, MCP flexion, IP extension brace
- flexion & ADD contracture: extension & ABD brace
5- Knee: flexion contracture
-position in extension, posterior knee splint
6- Ankle: PF contracture
-position in DF or neutral in AFO
Venous ulcers
Etiology:
- venous insufficiency
- valvular incompetence
- DVT
- venous HTN
- calf muscle pump failure
- varicose veins
S&S:
- can occur anywhere in lower leg; common over medial malleolus
- normal pulse
- pain: none to min in dependent position
- normal color or cyanotic in dependent posiiton
- –hemisiderosis dark pigmentation
- –liposclerosis- thick, tender, fibrosed
- normal temp
- edema: present, often marked
- ulceration: wet with large amount of exudate
Treatment:
- elevation and compression to control edema is vital (Unna boot, stockings, intermittent compression therapy)
- whirlpool NOT helpful d/t dependent position
- active exercise
- stockings long term
**ABI contraindicated if
Arterial ulcers
Etiology:
- chronic arterial insufficiency
- arteriosclerosis obliterans
- arthroembolism
- diabetes
S&S
- occurs in lower leg; typically lateral malleolus, shin and small toes
- decreased/absent pulse
- preceeded by intermittent claudication
- pain: often severe, intermittent, exacerbated with limb elevation
- color: pale with elevation, + rubor of dependency
- temp: cool
- skin changes: trophic changes (thin, shiny, atrophic skin); loss of hair on foot and toes; thickened nails
- ulceration: of toes or feet, can be deep
- gangrene: black, gangrenous skin adjacent to ulcer can develop
TX:
- bed rest, HOB elevated
- stop smoking
- wound care
- ROM
- wound VAC
- if ABI
diabetic ulcer
diabetes associated with arterial disease and peripheral neuropathy
-caused by repetitive trauma on insensitive skin
S&S:
- occurs where arterial ulcers occur or where peripheral neuropathy occurs (plantar foot
- pain: typically not painful d/t sensory loss
- pulses: present or diminished
- sepsis common; gangrene may develop
classification according to Wagner scale
Charcot foot: later stages secondar to decreased sensation
TX:
- standard ulcer management- decried necrotic tissue and promote moist wound healing
- offload ulcer from abnormal pressures
- shoe modification- use of rocker bottom shoe
Pressure ulcer (decubitus)
Caused by unrelieved pressure resulting in ischemic hypoxia and damage to underlying tissue
occurs over bony prominences
color: red, brown/black, yellow
can be painful is sensation intact
inflammatory response with necrotic tissue:
-hyperemia, fever, increased WBC
graded by stages of severity
Pressure ulcer scale and treatments
Stage I:
- non-blanchable erythema of intact skin
- reversible with intervention
- TX: pressure, friction and moisture alleviating measures
Stage II:
- partial thickness skin loss; involves epidermis and dermis
- presents as an abrasion, blister or shallow crater
- TX: if no infection an appropriate dressing occludes the wound from environment
Stage III:
- full thickness skin loss; involves damage to or necrosis of subcutaneous tissue but not through the fascia
- presents as a deep crater
- TX: often requires debridement, dressings and advanced pressure alleviating measures
Stage IV:
- full thickness skin loss; involves extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures
- TX: debridement, dressings, advanced pressure alleviating; surgery and grafting likely
Unstageable:
-tissue depth is obscured due to slough or escar and extent of damage can’t be determined
*If the wound is infected or not healing within 2 weeks, then antibacterial agents or a tx modality may be indicated
bone healing
occurs within a few days if the wound is not infected
process involves considerable hemorrhage, followed by proliferation of osteoblasts, then to the formation of a callus at about a week, which eventually remodels into bone
albumin
normal: 3-5-5-5 g/dL
methods of debridement
autolytic enzymatic mechanical sharp surgical
autolytic debridement
natural debridement promoted under occlusive or semi occlusive moisture-retentive dressings that results in solubilization of necrotic tissue only by phagocytic cells and by proteolytic and collagenolytic enzymes inherent in the tissues
Contraindications:
- infected wounds
- immunosuppressed patients
- dry gangrene or dry ischemic wounds
Enzymatic debridement
a selective method of chemical debridement that promotes liquefaction of necrotic tissue by applying topical preparation of collagenolytic enzymes to those tissues
Indications:
- moist necrotic wounds
- eschar after cross hatching
- homebound patients
- can’t tolerate surgical debridement
Contraindications:
- ischemic wounds unless adequate vascular status
- dry gangrene
- clean, granulated wounds
mechanical debridement
nonselective method
removes foreign material and contaminated tissue by physical forces
-wet-to-dry gauze dressing, whirlpool, suction
-may remove healthy tissue
Indications:
-wounds with moist necrotic tissue or foreign material present
Contraindications:
-clean, granulated wounds
sharp debridement
selective method
-uses sterile instruments that remove only necrotic wound tissue without anesthesia and with little or no bleeding
Indications:
-excision of leathery eschar
Contraindications:
- clean wounds
- advancing cellulitis with sepsis
- infection
- anticoagulant
surgical debridement
deep (stage III or IV) or complicated pressure ulcer
selective, performed by surgeon
- removes most/all necrotic tissue and maybe some healthy tissue
- requires anesthesia
Indications:
- advanced cellulitis with sepsis
- immunocompromised patients
- threatening infection
Contraindications:
- cardiac, pulmonary disease or diabetes
- severe spasticity
delays in wound healing
Intrinsic:
-aging, chronic diseases, circulator disease, malnutrition, neuropathy
Extrinsic
-meds (steroids), necrotic tissue, infection, excessive pressure, wrong dressing choice
Chronic inflammation can persist for months, years and delay wound healing due to necrotic tissue, colonization, infection or foreign materials present within the wound.
- often recognized by a wound not healing normally and/or a halo of redness or purple hue from an excessive release of histamine due to overreactive macrophages and mast cells
- source of inflammation must be resolved before haling can begin
types of union
Primary union:
- no major loss of CT
- sealing by blood clot within hours
- epithelialization and fibroblast proliferation 1-3 days
- subsequent formation of collagen tissues over period of weeks
- collagen eventually loses its excess vascular supply and tissue strength increases by end of 2 months
Secondary union:
- prolonged process of dermal healing that results from necrosis of tissue due to inflammation or traumatic destruction (pressure ulcer)
- delay of wound healing unless dead tissue and debris are removed from wound
- “beefy red” appearance indicates healthy healing and no debridement or chemical antibacterial agent needed
- moist wound healing should be promoted except in the presence of infection
Tertiary (delayed primary) union:
- dela in suturing of a site 5-7 is indicated in the presence of wound contamination, large tissue loss, or excessive edema
- healing sequence is similar to an injury treated with a primary union except for a delay of about a week
wound dressings
Functions:
- protect wooden from contamination and trauma
- permit application of meds
- absorb drainage
- debride necrotic tissue
- enhance healing
Dressing choices for a wound are based on 3 primary characteristics:
1- color
2- depth
3-exudate production
Dressings::
- gauze
- occlusive dressings
- alginates
- films
- foams
- hydrocolloid
- hydrogels
- nonadherent
- semirigid
- transparent
modalities that promote wound healing
iontophoresis with zinc or histamine
US to speed up healing
- low intensity, pulsed
- 3x/week
Estim
- increase wound healing
- reduce bacterial contaminants
- high volt pulsed current (HVPC)
- anode used to promote epithelial cell migration and for reactivation of inflammatory phase
- cathode used to promote granulation, control inflammation and inhibit certain bacteria
Wound VAC
- negative pressure system
- indicated when wound isn’t closing, lack of arterial perfusion or when excessive exudate that can’t be controlled with dressing
- applied continuously and in presence of infection
transparent films
clear, adhesive, semipermeable membrane
-permeable to oxgen and moisture vapor
Indications:
- stage I and II pressure ulcers
- autolytic debridement
Advantages:
- visual evaluation of wound without removal
- impermeable to external fluids and bacteria
- transparent and comfortable
- promote autolytic debridement
- minimize friction
Disadvantages:
- nonabsorptive
- difficult application
- not used on wounds with fragile skin or infection or copious drainage
Hydrocolloid dressings
adhesive wafers containing hydroactive/absorptive particles that interact with wound fluid to form a gelatinous mass over wound bed.
- may be either occlusive or semi-occlusive
- available in paste form as a filler for shallow cavity wounds
Indications:
- protection of partial thickness wounds
- autolytic debridement of necrosis or slough
- wounds with mild exudate
Advantages:
- maintains moist wound environment
- excellent bacterial barrier
- nonadhesive to healing tissue
- conformable
- supports autolytic debridement
- reduces pain
- easy to apply, time saving
- diminishes friction
Disadvantages:
- not used over infection
- nontransparent
- may soften and change shape with heat/friction
- not for wounds with heavy exudate or with fragile surrounding tissue
- dressing edges may curl
change 3-7 days and as needed with leakage
Hydrogel dressings
water or glycerine based gels
- insoluble in water
- available in solid sheets, amorphous gels, or impregnated gauze
- absorptive capacity varies
Indications:
- partial and full thickness burns
- wounds with necrosis and slough
- burns and tissue damaged by radiation
Advantages:
- soothing/cooling
- fill dead space
- rehydrate dry wound beds
- promotes autolytic debridement
- provides min to mod absorption
- conforms to wound bed
- transparent to translucent
- amorphous form can be used for infection
Disadvantages:
- most require secondary dressing
- not used for heavily exudated wounds
- may dry out and then adhere to wound bed
- may macerate surrounding skin
dressing changes every 8-48 hours
foam dressings
semipermeable membranes that are either hydrophilic (absorb moisture) on in inside and hydrophobic on the outside
-vary in thickness, absorptive capacity and adhesive properties
Indications:
- partial and full thickness wounds with min to moderate excudate
- secondary dressing for wounds with packing to provide additional absorption
- provide protection and insulation
Advantages:
- insulate wounds
- provide padding
- most are non adherent
- conformable
- manage min-heavy exudate
- easy to use
- some newer products designed for deep cavities
Disadvantages;
- nontransparent
- nonadherent require secondary dressing, tape or net to hold in place
- poor conformability to deep wounds
- not for use with dry eschar or wounds without exudate
change 1-5 days
Alginate dressing
soft, absorbent, non woven dressings derived from seaweed that have a fluffy cotton like appearance
- react with wound exudate to form a viscous hydrophilic gel mass over the wound area
- available in ropes and pads
Indications:
- wounds with mod-large amounts of exudate
- wounds with combo exudate and necrosis
- wounds that require packing and absorption
- infected and noninflected exuding wounds
Advantages:
- absorb 20x their weight in drainage
- fill dead space
- support debridement in presence of exudate
- easy to apply
Disadvantages:
- require secondary dressing
- not recommended for dry or lightly exudating wounds
- can dry wound bed
may use dry gauze or transparent film as secondary dressing
change 8 hours to 2-3 days
Gauze
made of cotton or synthetic fabric that is absorptive and permeable to water and oxygen
- may be used wet, moist, dry or impregnated with petrolatum, antiseptics, or other agents.
- com in varying weaves and with different sizes
Indications:
- exudative wounds
- wounds with dead space, tunneling or sinus tracts
- wounds with combo exudate or necrotic tissues
1-Wet-to-dry: mechanical debridement of necrotic tissue
2-Continous dry: heavily exudating wounds
3- Continuous moist: protection of clean wounds
-autolytic debridement of slough/eschar
-delivery of topical needs
Advantages:
- readily available
- used with appropriate solutions- gels, saline, antimicrobials to keep wound moist
- can be used on infected wounds
- good mechanical debridement if properly used
- cost effective
- effective delivery of topicals if kept moist
Disadvantages:
- delayed healing if used improperly
- pain on removal (wet to dry)
- labor intensive
- require secondary dressing
- avoid direct contact with granulating tissue
lack loosely or compromises BF and delays closure
semirigid dressing
unna boot is a pliable, non stretchable dressing impregnated with ointments
used for venous insufficiency ulcers to control for edema and help with healing
