Integumentary Flashcards
Inflammatory
1-10 days
Platelet activation/clotting.
Debris and necrotic tissue removed and bacteria killed via WBCs
Clean wound bed made, which signals tissue restoration and repair processes
Re-epithelialization occurs within 24 hours at wound borders
Proliferative phase
3-21 days
Formation of new tissue signals proliferative phase
Capillary buds and granulation tissue fills wound bed
Wound closure via epithelialization and wound contraction
Maturation/Remodeling phase
7 days-2 years
Initiated when granulation tissue and epithelial differentiation begin
Fiber reorganization and contraction shrink and thin the scar
Newly repaired tissue has 15% of pre-injury tensile strength and overtime can increase to 80%
Primary Intention
Edges are reapproximated and closed with suture, staples, or adhesives
Usually occurs in acute wounds with minimal tissue loss.
Secondary Intention
Wound closes on own without superficial closure
Usually with significant tissue loss or necrosis, irregular or nonviable wound margins that cannot be reapproximated, infection or debris
Teritary Intention
Also referred to as delayed primary intention healing
Wounds at risk for developing complications like sepsis or dehiscence
Wound left open temporarily then closed via primary intention
Arterial Insufficiency Ulcers
Due to inadequate circulation of oxygenated blood, often due to atherosclerosis
Characteristics • Lower 1/3 of leg, toes, web spaces • Smooth edges, well defined; lack of granulation, usually deep • Exudate minimal • Pain is severe • Pedal pulses diminished or absent • Edema normal • Skin temperature decreased • Thin, shiny skin with hair loss and yellow nails • Pain increases with leg elevation
General recommendations • Rest • Limb protection • Risk reduction education • Inspect legs and feet daily • Avoid unnecessary leg elevation • Avoid using heating pads or soaking feet in hot water • Wear appropriately sized shoes with clean, seamless socks
Venous Insufficiency Ulcers
Impaired venous function resulting in inadequate circulation and eventual tissue damage
Characteristics • Proximal to medial malleolus • Irregular shape; shallow • Exudate moderate/heavy • Pain mild to moderate • Pedal pulses normal • Edema increased • Skin temperature normal • Flaking, dry skin; brownish discoloration • Less pain with leg elevation
General recommendations
• Limb protection
• Risk reduction education
• Inspect legs and feet daily
• Compression to control edema
• Elevate legs above heart when resting or sleeping
• Attempt active exercise including frequent ROM
• Wear appropriately sized shoes with clean, seamless socks
Neuropathic Ulcers
Usually from ischemia and neuropathy. Often associated with diabetes.
Failure to perceive application of 10 gm monofilament indicates loss of protective sensation. Failure to perceive a 75 gm monofilament indicates that an area is insensate.
Characteristics
• Areas of foot susceptible to pressure or shear forces during weight bearing
• Well-defined oval or circle; callused rim; cracked periwound tissue; little to no wound bed necrosis with good granulation
• Exudate low/moderate
• No pain
• Pedal pulses diminished or absent
• Edema normal
• Skin temperature decreased
• Dry, inelastic, shiny skin; decreased or absent sweat and oil production
General recommendations
• Limb protection
• Risk reduction education
• Inspect legs and feet daily
• Inspect footwear for debris prior to donning
• Wear appropriately sized, off-loading footwear with clean, cushioned, seamless socks
Pressure Ulcers
Also called decubitus ulcers
Factors may include shearing forces, moisture, heat, friction, medications, muscle atrophy, malnutrition, and debilitating medical conditions.
Pressure injury risk assessment tools include Braden and Norton Scales
General Recommendations
• Repositioning every 2 hours in bed
• Management of excess moisture
• Off-loading with pressure relieving devices
• Inspect skin daily for signs of pressure damage
• Limit shear, traction, and friction over fragile skin
Stage 1 Pressure Ulcer
Non-blanchable erythema of intact skin
Non-blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes
Stage 2 Pressure Ulcer
Partial-thickness skin loss with exposed dermis
Wound bed is viable, pink or red, moist. May present as intact or ruptured serum-filled blister.
Granulation tissue, slough and eschar not present
Stage 3 Pressure Ulcer
Full-thickness skin loss
Adipose is visible and granulation tissue and epibole (rolled edges) often present
Slough and eschar may be visible
Undermining and tunneling may occur
Stage 4 Pressure Ulcer
Full-thickness skin and tissue loss
Exposed fascia, muscle, tendon, ligament, cartilage, or bone
Slough and eschar may be visible
Undermining and tunneling often occur
Unstageable
Obscured full-thickness skin and tissue loss
Extent of tissue damage cannot be confirmed because it is obscured by slough or eschar. If slough or eschar removed, a stage 3 or 4 pressure injury will be revealed. Stable eschar should not be removed from ischemic wound
Deep tissue pressure injury
Persistent non-blanchable deep red, maroon or purple discoloration
Intact or non-intact skin with persistent non-blanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.
Occurs from pressure and shear forces at the bone-muscle interface.
Superficial Wound
Causes trauma to skin with epidermis intact. Non-blistering sunburn. Will heal via inflammatory process
Partial Thickness Wound
Extends through epidermis and possibly into, but not through, the dermis. Include abrasions, blisters, and skin tears. Will heal by re-epithelialization or epidermal resurfacing.
Full Thickness Wound
Extends through dermis into structure like subcutaneous fat. Wounds deeper than 4 mm. Heal by secondary intention.
Subcutaneous Wound
Extend through integumentary tissue and involve subcutaneous fat, muscle, tendon, or bone. Heal by secondary intention.
Wagner Ulcer Grade Classification System
Categorizes ulcers based on wound depth and presence of infection. Often used for diabetic foot ulcers. Can be used for neuropathic, ischemic, arterial etiology wounds.
0 - No open lesions; may have deformity or cellulitis
1 - Superficial diabetic ulcer (partial or full thickness)
2 - Ulcer extension to ligament, tendon, joint capsule, or deep fascia without abscess or osteomyelitis
3 - Deep ulcer with abscess, osteomyelitis, or joint sepsis
4 - Gangrene localized to portion of forefoot or heel
5 - Extensive gangrenous involvement of the entire foot
Serous exudate
Clear, light color, and thin, watery consistency. Normal in healthy healing wound and observed during inflammatory and proliferative phases of healing
Sanguineous exudate
Red color and thin, watery consistency. May indicate new blood vessel growth or disruption of blood vessels.
Serosanguineous exudage
Light red or pink color; thin, watery consistency. Normal in healthy healing wound and usually occurs during inflammatory and proliferative phases of healing.
