Integumentary and Lymphedema Lecture Flashcards
what is the lymphatic system?
- the “drainage or sanitation” system
- includes lymph nodes, thymus, bone marrow, spleen, tonsils, Peyer patches of small intestine
what is the function of the lymphatic system?
- Remove waste products
- Remove excess fluid
- Alert immune system
- Return fluid and plasma proteins to the blood
-Fluid transport - Play a role in maintaining homeostasis
what are the stages of lymph formation?
A. Initial lymph vessel is empty and collapsed. The subsequent pre-collector is filled with lymph. The anchoring filaments and the fiber network are relaxed as the result of low interstitial pressure.
B. Filling phase - The interstitium is filled with fluid and thus the interstitial pressure exceeds the pressure in the initial lymph vessel. The interstitial fiber network and the anchoring filaments are tense and thus the outer swinging flap is pulled outside, whereas the inner ones are pushed inward by the fluid flowing inside: the inlet valves are open.
C. The initial lymph vessel is filled with lymph. The pressure in the initial lymph vessel exceeds the interstitial pressure and thus the inlet valves are closed.
D. The pressure inside the initial lymph vessels opens the valve to the pre-collector and thus the lymph flows toward the pre-collector.
how does lymph move?
-The valves function to move lymph in one-way
-Move 1-2 liters/day
-It moves fluid very slowly, has its own intrinsic contractions (not like vascular system that is moved by separate pump of the heart or active muscle pumping)
-There is no continuous column of fluid (vascular system moves fluid continuously)
what do the thoracic duct and lymphatic duct drain to?
The thoracic duct (green), discharges into the left subclavian vein, in the neck. The right lymphatic duct is also shown carries far less lymph than the thoracic duct, draining mainly the right arm and head, the heart and lungs, and the anterior chest wall
what is transport capacity and functional reserve?
- Transport capacity (TC) is the amount of fluid the system can move when working at maximum intensity
-Under normal conditions the system works at ~10% of normal capacity - Functional reserve (FR) is the difference between the TC and amount of fluid being transported at rest, known as the “lymphatic load” (LL)
-When additional fluid and protein increase in the soft tissues the lymphatic system will use FR to remove any excess
when does the lymphatic system become insufficient?
- Dynamic Insufficiency:
This can be caused in the healthy individual who sustains a sprained ankle, and the system has increased LL requiring it to work harder
Cause: immobility, CHF, sprained ankle…..anything increasing LL (higher output) - Mechanical Insufficiency:
This is caused by a damage to the lymphatic system, therefore unable to handle increased LL, i.e. Lymphedema which is the most common disruption to the system
Cause: surgery, infection, trauma…..anything reducing the transport capacity (TC) which is lowering the ability to remove fluid from the region - Combined Insufficiency
when does lymphedema develop? what are the consequences?
- Lymphedema develops when the TC drops below the LL amount resulting in accumulation of fluids in the subcutaneous tissue
- High-protein fluid causes fibrosis and sclerosis of the tissues and increases risk of infection
what is the clinical presentation of lymphedema?
- Slowly progresses
-Mild warmth - Rarely see color changes
- Usually, painless
- Sensation of fullness or heaviness in the limb
- Pitting edema or hard to palpation
- Asymmetrical comparison of limbs
what is the difference between lymphedema and edema?
lymphedema: +stemmer
pitting edema, underlying fibrosis of skin, tight and heavy limb, decreased mobility or loss of ROM, tingling or numbness in limb, pain or tenderness in surrounding joints, skin discolorations, common fungal infections, hardening of the skin, odor, wounds, decreased QOL
edema: - stemmer
Acute edema: rapid onset, red, warm, painful to palpation or movement, localized
Chronic edema: skin changes include hair loss, loss of tissue elasticity or skin creases, moderate warmth, hemosiderin staining, achy pain progressive through day, loss of normal contour in extremity
what are the lymphedema stages?
stage 0: latency; no clinical edema, - stemmer, normal skin, lymph transport capacity reduced
stage 1: reversible stage; soft and pitting edema, edema reversible with elevation, increased edema with standing, - stemmer, normal tissue
stage 2: spontaneously irreversible; edema present that can progress to nonpitting edema, not reversible with elevation, +stemmer, tissue is fibrosclerotic, frequent infection, skin changes
stage 3: lymphostatic elephantiasis; edema is severe and non pitting, does not reserve, +stemmer, tissue is fibrosclerotic, frequent infection, skin changes
What is cellulitis? what are common symptoms? when does it become a medical emergency?
-An infection of the skin caused by bacteria typically caused by an open wound
- common symptoms: redness, edema, tenderness, pain, warmth, blisters, fever, headache, chills, weakness, red streaks
- medical emergency when the area spread and becomes large, the skin changes color (black) or it affects the face
how is cellulitis diagnosed? what is the course of treatment? what are possible complications? what are prevention techniques?
- dx: blood tests and cell culture
- treatment: antibiotics, topical antibiotics, wound dressing, pain meds, surgery
- complications: extensive tissue damage, gangrene, infection to blood, sepsis, amputation, shock, death
-prevention: hygiene, protect dry skin, protective footwear, wound prevention
what are the layers of the skin organized from outermost to innermost layer?
- Epidermis is avascular and water-resistant and in normal, healthy conditions it repairs itself quickly
- Dermis is nearly 30x thicker than epidermis layer and contains blood vessels, lymphatic vessels, nerves, nerve endings, hair follicles, sweat glands
Dermis is surrounded by collagen, elastin, ground substance – provides elasticity, flexibility, structure to the skin - Subcutaneous layer is not part of integument but is the layer between dermis and underlying structures
Made up of connective tissue, fat = Protects underlying structures
what is the main function of the epidermis?
- maintain skin integrity as a physical barrier against bacteria, shear, friction, irritants, and protection against loss of fluid at the cellular level
what is the primary function of the dermis
provides tensile strength, support, retains moisture, blood, and O2 to the skin
how much blood circulates to the skin?
about 1/3 of circulating blood goes to the skin
what are the phases of wound healing? what if the phase is interrupted?
phase 1: inflammatory phase (1-10 days); if interrupted chronic inflammation cycle can occur
phase 2: proliferative phase (3-21 days); if interrupted can result in a chronic wound
phase 3: maturation phase (7days- 2 years); scar tissue will remodel but the strength will be 80% of normal tissue
what influences wound healing?
age, comorbidities, edema, inappropriate wound care, infection, lifestyle, stress, medications
what is essential for healthy skin? what will compromise a wound site?
- proper functioning peripheral vascular system and lymphatic system
- oxygen
- arterial insufficiency, edema, necrosis
what is essential in a wound healing environment? How do you promote that?
- a moist wound healing environment is the most important external factor for optimal wound healing
- barrier of the wound should be “breathable” and preserve fluid, maintain peri wound integrity, and change bandages when leakage occurs outside of borders
documentation of wounds should include (8)
- location
- size
- shape
- edges
- tunneling, undermining, and sinus tracts
- base (necrosis, exudate, granulation)
- peri-wound area (edema or maceration
- pain
what is serous drainage? what is the color, thickness, and during what healing phase does it occur?
- color: clear and light
- thickness: thin and watery
- healing phase: inflammatory and proliferative
what is sanguineous drainage? what is the color, thickness, and during what healing phase does it occur?
- color: red color
-thickness: thin and watery - healing phase: inflammatory and proliferative phase
what is serosanguineous drainage? what is the color, thickness, and during what healing phase does it occur?
-color: clear and tinge light of red and pink
-thickness: thin and watery
-healing phase: inflammatory and proliferative
what is seropurulent drainage? what is the color, thickness, and during what healing phase does it occur?
- color: cloudy, opaque, yellow or tan
- thickness: thin and watery
- healing phase: early warning signs of infection (abnormal findings)
what is purulent drainage? what is the color, thickness, and during what healing phase does it occur?
-color: yellow, green
-thickness: thick and viscous
-healing phase: wound infection (abnormal finding)
what is necrotic tissue?
“devitalized” or “non-viable” tissue
what is slough tissue?
moist, stringy or mucinous white/yellow tissue that is attached to wound bed but easily removed
what is eschar tissue?
hard, leathery, black/brown, dehydrated tissue and is usually adhered to healthy tissue underneath
what is gangrene tissue?
death and decay of tissue due to interrupted blood flow
what is hyperkeratosis tissue?
“callus” white/gray, texture firm to soggy depending on moisture surrounding it
what is primary intention?
- the surgeon closes wound edges by approximating and using sutures, staples, grafts, glue
-If infection or maceration causes this to open …. “dehiscence”
what is secondary intention?
- When a wound is left to heal on its own
- New tissue laying down in wound bed closes the area until it is healed from the deepest layers to most superficial
what is tertiary intention?
- Delayed primary”
- When secondary intention fails and then surgically closed
- When delay is purposeful it is usually because of infection
- Once healed ….. then closure occurs
what are clinical signs that a wound is not healing?
- Change in color
- Change in odor
- Persistent edema
- Necrotic tissue formation
- Tunneling or undermining
Infection - Wound edge builds up a ridge that curls under itself
- Hypertrophic scarring or keloid
what are the clinical features of a venous ulcer?
- pulses: normal
-pain: none to aching
-color: normal or cyanotic (dark pigmentation)
-temperature: normal - edema: often marked
- skin changes: pigmentation, statis dermatitis, thickening of skin as scarring develops
- ulceration: can develop on medial ankle especially in wet areas
-gangrene: absent
what are the clinical features of a arterial ulcer?
- pulses: poor or absent
-pain: severe, intermittent claudication, pain at rest
-color: pale on elevation, dusky rubor
-temperature: cool - edema: usually absent
- skin changes: trophic changes (thin, shiny, atrophic skin) (loss of hair on foot or toes) (nail thicken)
- ulceration: on toes or feet that can be deep
-gangrene: black gangrenous skin adjacent to the ulcer
what are the clinical features of a diabetic ulcer?
- pulses: may be present or diminished
-pain: typically not painful as there is sensory loss
-color: normal or cyanotic (dark pigmentation)
-temperature: - edema:
- skin changes:
- ulceration: may develop due to trauma insensitive skin
-gangrene: can develop if left untreated
what are the clinical features of a pressure ulcer?
- pulses:
-pain: can be painful if sensation is intact
-color: red, brown/black, yellow
-temperature: may be warm if localized infection present (associated fever) - edema:
- skin changes: inflammatory response with necrotic tissue
-ulceration: over bony prominences (sacrum, heels, trochanter, lateral malleolus, ischial area, elbows) - gangrene: may develop if left untreated
what are the sections for the Braden Scale for predictions of pressure sores?
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
Stage 1 pressure ulcer
- intact skin with non-bleachable redness of a localized area usually over a bony prominence
-darkly pigmented skin may not have visible bleaching - can be painful, warm, soft, firm
stage 2 pressure ulcer
partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough
stage 3 pressure ulcers
- full thickness loss, subcutaneous fat visible but fascia and structures below are not exposed
stage 4 pressure ulcers
full thickness tissue loss with exposed bone , tendon, muscle.
suspected deep tissue injury
purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear
Wagner diabetic ulcer stage 0
No open lesion, may have pre-ulcerative lesions (healed ulcer, or presence of bony deformity)
Wagner diabetic ulcer stage 1
Superficial ulcer, does not involve any subcutaneous tissue
Wagner diabetic ulcer stage 2
Deep ulcer penetrating through subcutaneous tissue, has potential to expose bone, tendon, ligament, joint capsule
Wagner diabetic ulcer stage 3
Deep ulcer with osteitis, abscess, or osteomyelitis
Wagner diabetic ulcer stage 4
Gangrene
Likely requiring amputation
Wagner diabetic ulcer stage 5
Gangrene
Suspected deep tissue injury, requiring amputation
what is the wagner diabetic ulcer grade classification used for?
Wagner scale assesses depth of an ulcer and presence of osteomyelitis or gangrene
