Integumentary: General Overview Flashcards
Arterial Insufficiency Ulners:
Location, Appearance, Exudate, Pain, Pedal Pulses, Edema, Skin Temperature, Tissue Changes
Lower 1/3 of leg, toes, web-spaces, dorsal foot, lateral malleolus Smooth edges, well defined; lack granulation; deep Minimal Exudate Severe Pain Diminished or absent Pulse No edema Decreased skin temp Thin and shiny; hair loss; yellow nails
Venous Insufficiency Ulcers:
Location, Appearance, Exudate, Pain, Pedal Pulses, Edema, Skin Temperature, Tissue Changes
Proximal to medial malleolus Irregular shape; shallow Moderate/heavy exudate Mild/moderate Pain Normal Pedal Pulse Increased Edema Flaking, dry skin; brownish discoloration
Neuropathic Ulcers:
Location, Appearance, Exudate, Pain, Pedal Pulses, Edema, Skin Temperature, Tissue Changes
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
Low/moderate exudate
No pain (dyesthesia reported)
Diminished/absent pulse; unreliable ankle-brachial index with diabetes
No edema
Decreased skin temp
Dry, inelastic, shiny skin; decreased or absent sweat and oil production
Wagner Classification Scale:
no open lesion, but may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity
0
Wagner Classification Scale:
Superficial ulcer not involving subcutaneous tissue
1
Wagner Classification Scale:
Deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament or joint capsule
2
Wagner Classification Scale:
Deep ulcer with osteitis, abscess or osteomyelitis
3
Wagner Classification Scale:
Gangrene of digit
4
Wagner Classification Scale:
Gangrene of foot requiring disarticulation
5
Pressure Ulcer Staging:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. May be painful, firm, soft, warmer/cooler as compared to adjacent tissue.
Stage I
Pressure Ulcer Staging:
Partial-thickness tissue loss of the dermis presenting as a shallow open ulcer with a red or pink wound bed. May present as an intact or ruptured serum-filled blister or presents as a shiny or dry shallow ulcer without slough or bruising.
Stage II
Pressure Ulcer Staging:
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage III
Pressure Ulcer Staging:
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling may be present.
Stage IV
Pressure Ulcer Staging:
Purple or maroon localized areas of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear forces. Tissue preceding area may be abnormal compared to adjacent tissue.
Suspected Deep Tissue Injury
Pressure Ulcer Staging:
Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
Unstageable
Exudate Classification:
Clear, light color and a thin watery consistency
Serous
Exudate Classification:
Red color and a thin, watery consistency (indicative of new blood vessel growth or the disruption of blood vessels)
Sanguineous
Exudate Classification:
Light red or pink color and a thin, watery consistency.
Serosanguineous
Exudate Classification:
Presents as cloudy or opaque, with a yellow or tan color and a thin, watery consistency.
Seropurulent
Exudate Classification:
Presents with yellow or green color and a thick viscous consistency
Purulent
Necrotic Tissue Types:
Hard or leathery, black/brown, dehydrated tissue that tends to be firmly adhered to the wound bed
Eschar
Necrotic Tissue Types:
Death and decay of tissue resulting from an interruption in blood flow to an area of the body.
Gangrene
Necrotic Tissue Types:
Referred to as callus, is typically white/gray in color and can vary in texture from firm to soggy depending on the moisture level in surrounding tissue
Hyperkeratosis
Necrotic Tissue Types:
Moist, stringy or mucinous, white/yellow tissue that tends to be loosely attached in clumps to the wound bed
Slough
Use of a scalpel, scissors, and/or forceps to selectively remove devitalized tissue, foreign material or debris from a wound. Most expedient form of removing necrotic tissue
Sharp Debridement
Topical application of enzymatic preparation to necrotic tissue. Slow to establish a clean wound bed and should be discontinued once devitalized tissue is removed to avoid damage to adjacent healthy tissue
Enzymatic Debridement
Use of transparent films, hydrocolloids, hydrogels, and alginates. Establishes a moist wound environment that rehydrates necrotic tissue and eschar, facilitating enzymatic digestion of the nonviable tissue.
Autolytic Debridement
Application of a moistened gauze dressing over an area of necrotic tissue. Allowed to dry and is later moved.
Wet-to-dry Dressings
Removes necrotic tissue form wound bed using pressurized fluid. i.e. pulsatile lavage
Wound Irrigation
Most commonly employed using a whirlpool tank with agitation directed toward a wound requiring debridement.
Hydrotherapy
An injury, usually caused by a blow, that does not disrupt skin integrity. Characterized by pain, edema, and dislocation which appears as a result of blood seepage under the surface of the skin
Contusion
The separation, rupture or splitting of a wound closed by primary intention
Dehiscence
Drying out or dehydration of a wound. Results from poor dressing selection that does not control the evaporation of wound bed moisture
Desiccated
Peeling or shedding of the outer layers of the epidermis. Normally occurs in small scales, although certain conditions, injuries, and medications may cause peeling larger scales or sheets and extend to deeper layers of the skin.
Desquamation
Discoloration occurring below intact skin resulting from trauma to underlying blood vessels and blood seeping into tissues. Typically blue-black, changing in time to a greenish brown or yellow color.
Ecchymosis
Diffuse redness of the skin often resulting from capillary dilation and congestion or inflammation
Erythema
Tissue that readily tears, fragments or bleeds when gently palpated or manipulated
Friable
Localized swelling or mass of clotted blood confined to a tissue, organ or space usually caused by a break in a blood vessel
Hematoma
Increased thickness of the granular layer of the epidermis that exceeds the surface height of the skin
Hypergranulation
Excess of pigment in a tissue that causes it to appear darker than surrounding tissue
Hyperpigmentation
Abnormal scar resulting from excessive collagen formation during healing. Typically raised, red, and firm with disorganized collagen fibers
Hypertrophic scar
Abnormal scar formation that is out of proportion to the scarring required for normal tissue repair and is comprised of irregularly distributed collagen bands. Typically exceeds the boundaries of the original wound appearing red, thick, raised, and firm
Keloid
Skin softening and degeneration that results from prolonged exposure to water or other fluids
Maceration
Scar characterized by the organized formation of collagen fibers that align in a parallel fashion
Normotrophic scar
The relative speed with which the skin resumes its normal appearance after being lightly pinched. Indicator of skin elasticity and hydration and normally occurs more slowly in older adults
Turgor
Open sore or lesion of the skin accompanied by sloughing of inflamed necrotic tissue
Ulcer
Area of the burn that received the most severe injury with irreversible cell damage
Zone of coagulation
Area of less severe injury that possesses reversible damage and surrounds the zone of coagulation
Zone of stasis
Are surrounding the zone of stasis that presents with inflammation, but will fully recover without any intervention or permanent damage
Zone of hyperemia
Burn involves only the outer epidermis. Healing occurs without peeling or evidence of scarring in 2-5 days
Superficial burn
Burn involves the epidermis and the upper portion of the dermis. Involved area may be extremely painful and exhibit blisters. Healing occurs with minimal to no scarring in 5-21 days.
Superficial partial-thickness burn
Burn involves complete destruction of the epidermis and the majority of the dermis. Damage to nerve endings may result in only moderate levels of pain. Hypertrophic or keloid scarring may occur. Healing will occur in 21-35 days.
Deep partial-thickness burn
Burn involves complete destruction of the epidermis and dermis along with partial damage to the subcutaneous fat layer. Presents with eschar formation and minimal pain. Healing time varies
Full-thickness burn
Burn involves the complete destruction of the epidermis, dermis, and subcutaneous tissue. May involve muscle and bone.
Subdermal burn
Rule of Nines:
Head and neck
9%
Rule of Nines:
Anterior trunk
18%
Rule of Nines:
Posterior trunk
18%
Rule of Nines:
Bilateral anterior arm, forearm, and hand
9%
Rule of Nines:
Bilateral posterior arm, forearm, and hand
9%
Rule of Nines:
Genital region
1%
Rule of Nines:
Bilateral anterior leg and foot
18%
Rule of Nines:
Bilateral posterior leg and foot
18%
Rule of Nines: Child Values
Under 1 year has 9% taken from lower extremities and added to head and neck. Each year of life, 1% is distributed back to the lower extremities until the age of nine
Used with/without dressings
Painless
Can be applied to wound directly
Effective against yeast
Silver Sulfadiazine
Non-allergenic
Dressing application is painless
Silver Nitrate
Antifungal
Easily removed with water
Not effective against pseudomonas
Povidone-iodine
Penetrates burn eschar
May be used with/without occlusive dressings
Painful
Mafenide Acetate
May be covered or left open to air
Ototoxic and Nephrotoxic
Gentamicin
Bacteriocidal
May lead to overgrowth of fungus and pseudomonas
Nitrofurazone
A skin graft that contains the dermis and epidermis
Full-thickness graft
A temporary skin graft taken from another species
Heterograft (xenograft)
Skin graft that is transferred directly from the unburned donor site to the prepared recipient site
Sheet graft
A skin graft that contains only a superficial layer of the dermis in addition to the epidermis
Split-thickness graft
Surgical procedure to eliminate a scar contracture. An incision in the shape of a āZā allows the contracture to change configuration and lengthen the scar
Z-plasty
