Integumentary Flashcards
What are the layers of the skin?
Epidermis
Dermis
What is the function of the epidermis?
- temperature regulation
- moisture regulation
- sensation
- protection from infection/disease
- cosmesis
- interaction with the environment
What are the 5 layers of the epidermis?
“Come, Let’s Get a Sun Burn”
- Stratum Corneum
- Stratum Lucidium
- Stratum Granulosum
- Stratum Spinosum
- Stratum Basale
What are the other important epidermal cells?
- melanocytes
- merkel cells
- langerhans cells
What is the function of melanocytes?
- produce melanin to give skin its pigment and protect from harmful UV rays
What is the function of Merkel cells?
- specialized mechanoreceptors to provide information about light touch
What is the function of Langerhans cells?
- located in the deeper epidermal layers
- help fight infection by attacking and engulfing foreign material
What is the function of the dermis?
- 2 layers that are highly vascularized
- fibroblasts in this layer produce collagen and elastin
- nerve endings located here
- contains support structures: hair follicles, sudoriferous glands, sebaceous glands, vasculature, and lymphatics
What are the risk factors that increase the risk of wounds and impaired wound healing?
- medications (anticoagulants, steroids, immunosuppressants)
- diabetes (chronic blood sugar > 250)
- tobacco use
- poor nutritional status (especially protein –> look at albumin & pre-albumin)
- CV comorbidities (arterial/venous disease, heart failure)
- reactive/autoimmune processes
- reduced mobility
Define a decubitus ulcer
- a lesion caused by unrelieved pressure resulting in damage to the underlying tissues
Where do decubitus ulcers typically occur?
over bony prominences
- sacrum
- heels
- ischial tuberosity
- greater trochanter
What is the pathogenesis of decubitus ulcers?
pressure –> ischemia –> tissue necrosis
Describe a stage 1 decubitus ulcer
- non-blanchable erythema of intact skin
- lesion of skin ulceration
- discoloration of skin in individuals with darker skin
- warmth
- edema
- induration
- hardness
Describe a stage 2 decubitus ulcer
- partial-thickness skin loss involving epidermis, dermis or both
- superficial and presents clinically as an abrasion
- blister
- shallow center
Describe a stage 3 decubitus ulcer
- full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia
- presents clinically as a deep crater with or without undermining of adjacent tissue
Describe a stage 4 decubitus ulcer
- full-thickness skin loss with extensive destruction
- tissue necrosis
- damage to muscle, bone, or support structures
- undermining and sinus tracts may also be associated
- assume the patient has osteomyelitis
What colors may a decubitus ulcer present with?
- red
- brown
- black
- yellow
What should be noted about decubitus ulcers
- can have a localized, self-limiting infection
- foul smelling exudate may be present
- wound may be painful unless pt has decreased sensation
How is a decubitus ulcer prevented?
- bed positioning (change ever two hours)
- WC cushioning and unweighting/pressure relief exercises
- if the patient is unable to perform pressure relief, a tilt in space WC may be appropriate
Name the stages of burns
- first degree (superficial burns)
- second degree (partial thickness burns)
- third degree (full thickness burns)
Describe a first degree burn
- only epidermis affected
- skin is red, dry, and painful
- no blisters
- usually heals within 1 week
- no long-term damage
Ex: sunburn, burn from curling iron
Describe a second degree burn
- epidermis and part of dermis damaged
- skin is red, blistered, swollen, and painful
- skin may appear wet or shiny
- skin may be white/irregularly discolored
- dressing changes may be painful
- may heal in 3 weeks (or require more advanced management)
- can be classified as superficial or deep
Describe a third degree burn
- epidermis and entire dermis are damaged
- dry, leathery skin
- brown, yellow, or black skin
- no pain due to burned nerve endings
- requires extensive medical management for healing
What is the Rule of 9’s used for?
to calculate the total surface area for a burn injury
For the Rule of 9’s:
What percent are the head, chest, abdomen, upper back, and lower back?
9% each
For the Rule of 9’s:
What percent is a single arm?
9%
4.5% for the front and 4.5% for the back
For the Rule of 9’s:
What percent is a single leg?
18%
9% for the front and 9% for the back
For the Rule of 9’s:
What percent are the genitals?
1%
What medical issues should be of concern following a burn injury?
- pain management
- electrolyte/fluid management
- nutrition
- wound care (antimicrobials, skin substitutes)
- infection prevention
- pulmonary status
- psychological adjustment support
- surgery and skin graft management
What PT interventions are used to address burn injuries?
- contracture management
- positioning
- splinting
- scar management
- prevention of wound infection
- improve mobility and CV function
Why is contracture management so important following a burn injury?
- a healing scar is at a high risk for contracture development which can significantly impact function
When is positioning key? What should be considered?
For acute injury and managing post-surgical edema
- consider use of pillows, towels, wash cloths
When is splinting required? What are the goals?
- required with increased burn depth
- collaboration with OT needed
- goals: to promote neutral alignment for optimal function
What is the preferred position of the neck for positioning?
extension, no rotation
What is the preferred position of the shoulder for positioning?
abduction to 90
ER
horizontal flexion to 10
What is the preferred position of the elbow and forearm for positioning?
extension with supination
What is the preferred position of the wrist for positioning?
neutral or slight extension
What is the preferred position of the hand for positioning?
Dorsal Burn:
- functional position
Palmar Burn:
- finger and thumb extension
What is the preferred position of the trunk for positioning?
straight postural alignment
What is the preferred position of the hip for positioning?
neutral extension/flexion
neutral rotation
slight abduction
What is the preferred position of the knee for positioning?
extension
What is the preferred position of the ankle for positioning?
neutral or slight DF
no inversion
neutral toe extension/flexion
Which types of burns are more likely to have significant scars?
the severity of the burn and the person’s ethnicity are related to the amount of scar formation
What are 2 types of scars following a burn injury?
- Hypertrophic scars
- Keloid scars
Describe hypertrophic scars
- raised above the normal skin surface
- occur at the time of injury
Describe keloid scars
- grow beyond the area of the original injury
- grow months/years after injury
What is scarring following a burn injury related to?
- growth of collagen fibers in disorganized manner
- lack of balance between deposition and breakdown
How are compression garments used for scar management?
- customized to patient
- frequent re-assessment
- worn for 6-12 months
- can be used to protect tissues when grafting is delayed
- worn for 23hrs/day
What are the goals for compression garments?
- scar maturation
- protection of healing skin
- shrink the scar
What is the typical compression for a garment worn for scar management?
24-30mmHg
What are other scar management techniques?
- silicone sheets
- scar massage
- injections
- surgery
Describe how silicone sheets are used in scar management?
- applied under compression garments or where garments cannot conform to skin
- comfortable and do not restrict movement
- worn for 6-12 months, >20hrs/day
- some studies show reduction in scars with prolonged application/wear time
How is scar massage done?
- perpendicular to collagen fibers
- moisturizing with appropriate lotions
How are injections used for scar management?
- corticosteroids are injected into the scar 3-4 times every month
How is surgery used for scar management?
- used as a last resort, only if the scars severely impact function
- creates a new wound so that a cycle of healing begins again
What are the different types of burns?
- thermal
- electrical
- chemical
- UV and ionizing radiation
What are general wound principles?
- pressure ulcer prevention
- off-loading
- Braden scale (predicts pressure sore risk)
What are the components of a nutritional assessment?
- nutrition
- hydration
- education
What are the components of wound preparation?
- infection control
- debridement
- cleansing
What are the components of a wound environment?
- moist environment
- protection from heat and cold
- packing
- removing excess drainage
What is assessed during wound care?
- location of wound
- size of wound (depth, tunneling, undermining)
- tissue types
- exudate
- periwound skin
- abscess
What should be kept in mind during debridement?
- infection/inflammation control
- moisture balance
- edge/environment
- support with products, services, and education
What are the types of debridement?
- mechanical debridement
- autolytic debridement
- enzymatic debridement
- surgical debridement
What are the characteristics of the ideal dressing?
- manages exudate appropriately
- allows for gaseous exchange
- impermeable to bacteria, minimizes contamination
- free from particulate or toxic contamination
- non-traumatic or minimally painful on removal
What are some general desired attributes when selecting dressings?
- provides environment for healing
- user-friendly
- cost-effective
- compatible with support needs
- minimize need for secondary dressing when able
- use in infected wounds
- remain in place for expected time frame
What are the different types of dressings?
- transparent film
- hydrogels
- foam
- calcium alginates
- hydrocolloids
- hydrofibers
- medical grade honey
- collagenase
- silver sulfadiazine
- skin substitutes
How is ABI used during assessment of diabetic foot ulcers?
ABI = ankle systolic pressure/brachial systolic pressure
- used for a vascular exam of the pt
What are the values for ABI?
Normal: 0.9 - 1.3 Mild: 0.7 - 0.89 Moderate: 0.4 - 0.69 Severe: <0.4 Non-compressible vessels: >1.30
What does the Diabetic Foot Risk Classification tell us?
provides the percent of risk of foot ulcer and amputation based on medical status
What does the Wagner Ulcer Classification System tell us?
assesses ulcer depth and presence of gangrene and loss of perfusion
- does not fully address infection and ischemia
What does the University of Texas Wound Classification System tell us
assesses ulcer depth, presence of infection, presence of signs of LE ischemia
- describes the presence of infection and ischemia better than Wagner
- may help in predicting the outcome of the diabetic ulcer
