Integumentary - other systems Flashcards
Alginates Dressings
High absorption, high permeability, non occlusive,
- requires secondary dressing
- Acts as hemostat, creates hydrophilic gel
For FULL THICKNESS or PARTIAL
DRAINING WOUNDS Pressure or VI ulcers
Infected wounds
ABSORB excess exudate - maintain moist environment. barrier against bacteria
Foam Dressings
- Hydrophilic polyurethane base contacts wound surface, hydrophobic outer layer absorbs exudate
Full thickness or Partial wound - MIN-MOD draining
Can be used as secondary
Permeable to O2
Encourages autolytic debridement
Gauze Dressing
From yarn or thread
Impregnated with petrolatum, zinc, antimicrobials
Can have a chance for increased infection rates
Hydrocolloids
Gel forming polymers (gelatin, pectin, cellulose) + strong film
- Partial or FULL thickness wounds + granular + necrotic wounds. Protection for microbial contamination.
DO NOT USE on infected
Hydrogels
Water and gel forming (glycerin)
SUPERFICIAL or PARTIAL thickness (blisters, abrasions, pressure ulcers)
coupling for US
Transparent FIlm
Polyurethane w/ water resistant
Permeable to O2 and vapors, impermeable to bacteria and water
SUPERFICIAL or PARTIAL thickness MIN drainage (scalds, abrasions, lacerations)
Most to least Occlusive dressings
Hydrocolloids, hydrogels, semipermeable foam, semipermeable film, impregnated gauze, alginates, traditional gauze
Most to least moisture retentive
Alginates, semipermeable foam, hydrocolloids, hydrogels, semipermeable films
Wagner Ulcer Grade 0
No open lesion, may possess pre ulcerative lesions; healed ulcers, presence of bony deformity
Wagner Ulcer Grade 1
Superficla ulcer not involving subcutaneous tissue
Wagner Ulcer Grade 2
Deep ulcer with penetration through the subcutaneous tissue, potentially exposing bone, tendon, ligament or joint capsule
Wagner Ulcer Grade 3
Deep ulcer with osteitis, abscess or osteomyelitis
Wagner Ulcer Grade 4
Gangrene of digit
Wagner Ulcer Grade 5
Gangrene of foot requiring disarticulation
Stage 1 pressure ulcer
Non blanch-able erythema of intact skin
may indicate deep pressure injury, color changes dont include maroon or purple
Stage 2 pressure ulcer
Particial thickness skin loss with exposed dermis
Wound bed is pink or red, moist, present as an intact or ruptured serum-filled blister
Adipose not visbile
Granulationtissue, slough and eschar are not present
SHEER
Stage 3 pressure ulcer
Full thickness skin loss
Adipos is visiable, epibole (Rolled edges) present
Slough and escar may be visable, muscle/tendon/ligament not exposed
Stage 4 pressure ulcer
Full thickness skin and tissue loss
Directly exposed or palpable fascia, muscle, tendon, ligament, bone. Slough or eschar may be visible.
Epibole often occur
Unstageable pressure ulcer
Obscured full thickness skin and tissue loss
when removed can be a stage 3 or 4
Deep tissue pressure Injury
Persistent non blanch-able deep red, maroon, purple discoloration
Phases of healing of wound healing: Inflammatory
1 - 10 days
-Platelet activation and clotting cascade
- Debris and necrotic tissue removed and bacteria killed by mast cells, neutrophils, and leukocytes
- establish clean wound bed and signal repair
- Reepithelization occurs 24 hrs at wound borders, visible 3 days after injury
Phases of healing: proliferation
3 - 21 days
- Formation of new tissue signals - Formation of new tissue
- Capillary buds and granulation tissue begin to fill wound bed creating a support structure for epithelial cells.
- Keratinocytes, endothelial cells, fibroblasts are active and collagen matrix is formed.
- Wound closure through epithelialization, and wound contraction
Phases of healing: Maturation
7 days to 2 years
- Remodeling phase
- Granulation and epithelial DIFFERENTIATION begin to appear in the wound bed
- Hypertrophic scarring in burns affect healing
Primary intention
In acute wounds with min tissue loss
SMooth clean edges reapproximated and closed with sutures, staples, adhesives to facilitate reepithelialization
Superficial partial thickness = primary intention
72 hours
Min scarring and heal quickly (surgical, laceration, puncture, superficial/partial thickness)
Secondary Intention
Wounds close on their own without superficial closure
Wounds with significant tissue loss, necrosis, irregular wound margins that cannot be approximated, infection, debris contamination
Associated with diabetes, ischemic conditions, pressure damage, or inflammatory response.
Ongoing wound care with significant scarring (neuropathic ulcers, arterial, venuos, pressure ulcers, FULL thickness wounds)
Tertiary intention
Delayed primary intention healing
Wounds at risk for getting complications: sepsis, dehscience
Once cleared of infection or other complications then primary intention occurs
Hyperkaratosis
Hyperkeratosis, also 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.
Serous
Presents with clear, light color and a thin, water consistency. Normal in healthy healing
Observed in inflammatory and proliferative phases of healing
Sanguineous
Presents with red color and a thin, watery consistency.
Presence of blood which may become brown if dehydrated.
Indicative of new blood vessel growth or the disruption of blood vessels
Serosanguineous
Light red or pink color and a thin, watery consistency
NORMAL in healthy healing wound and observed in inflammatory and proliferative phase of healing
Seropurlent
Cloudy or opaque, with yellow or tan color and thin and watery consistency
Early warning sign of impending infection and is ABNORMAL
Purulent
Yellow or green color and a thick, viscous consistency
Red - RYB system
Pink granulation tissue
Protect wound; maintain moist environment
Yellow - RYB system
Moist yellow slough
Remove exudate and debris; absorb drainage
Black - RYB system
Black thick eschar firmly attached
Debride necrotic tissue
Dehiscience
Separation, rupture, or splitting of a wound by primary intention.
Superficial or involve all layers
Dessicated
Drying out or dehydrated wound
Poor dressing selection
Desquamation
peeling, shedding of outer layers
Eccymosis
Discoloration below intact skin from trauma and blood seeping into the tissues
Induration
Induration refers to the hardening of a normally soft tissue or organ. The hardening most commonly occurs because of inflammation, infiltration of a neoplasm, or an accumulation of blood.
Arterial Insufficiency Ulcers
Location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc
Secondary to inadequate circulation of oxygenated blood (ischemia) from athlerosclerosis
Location: Lower 1/3 of leg, toes, distal web spaces
Appearance:Smooth edges, well defined; lack granulation tissue; tend to be deep
Exudate: minimal
Pain: Severe
Pedal pulses: Diminished/absent
Edema: normal
Skin temp: decreased
Tissue changes: Thin and shiny; hair loss; yellow nials
Misc: Leg elevation increases pain
AI recommendations
Rest
Limb protection
Risk reduction education
Inspect legs and feet DAILY
Avoid unnecessary leg elevation
Avoid heating pads or soaking feet in hot water
Wear appropriately sized shoes with clean, seamless socks
Venous insufficiency ulcers
Location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc
Impaired function of venous system; inadequate circulation leading to tissue damage and ulceration
Location: proximal to the medial malleolus
Appearance: irregular shape; shallow
Exudate: moderate/heavy
Pain: Mild-Mod
Pedal pulses: normal
Edema: increased
Skin temp: Normal
Tissue changes: Flaking, dry skin, brownish discoloration
Misc: leg elevation lessens pain
VI recommendations
Limb protection
Risk reduction education
inspect legs and feet daily
Compression to control edema
Elevate legs above heart when sleeping or resting
Attempted active exercise including frequent ROM
Wear appropriately sized shoes with lean, seamless socks
Neuropathic Ulcers
Location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc
Complication with ischemia and neuropathy. Associated with DM
Location: Areas of the foot susception to pressure or shear forces during WBing
Appearance: Well defined oval/circle; callused rim; cracked periwound tissue; little to no wound bed necrosis with good granulation
Exudate: low-mod
Pain: none: dysesthesia may be reported
Pedal pulses: diminished/abset; unreliable ABI index with DM
Edema: normal
Skin temp: decreased
Tissue changes: Dry; inelastic, shiny skin; decreased absent sweat/oil production
Misc: loss of protective sensation
Neuropathic Ulcer recommendations
Limb protection
Risk reduction education
Inspect legs and feet daily
Inspect footwear prior to donning
Wear appropriately sized off loading footwear with clean, cushioned, seamless socks
Pressure ulcers
Decubitus ulcers; from sustained/prolonged pressure on tissue greater than capillary pressure.
Present as bruising or purple blisters intact skin before opening Full thickness damage.
Braden Scale/Norton Scale
Pressure ulcer recommendations
Reposition every 2 hours
Management of excess moisture
Offload pressure relieving devices
Inspect skin daily
Limit shear, traction and friction forces over fragile skin
Superficial Wound
Trauma to epidermis in tact
sunburn non blistering
heal normal inflammatory process
Partial thickness wound
Through epidermis not through dermis
abrasions/blisters/skin tears
heal by re-epitheliazation or epidermal resurfacing
Full thickness wound
through dermis and to subcutanouse fat. Deeper than 4mm
Heal by secondary intention
Subcutaneous Wound
Extends through integumentary tissues, deeper structures fat, muscle, tendon,bone, muscle
Heal by secondary intention
