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NPTE > Integumentary - other systems > Flashcards

Integumentary - other systems Flashcards

1
Q

Alginates Dressings

A

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

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2
Q

Foam Dressings

A
  • 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

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3
Q

Gauze Dressing

A

From yarn or thread

Impregnated with petrolatum, zinc, antimicrobials

Can have a chance for increased infection rates

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4
Q

Hydrocolloids

A

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

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5
Q

Hydrogels

A

Water and gel forming (glycerin)

SUPERFICIAL or PARTIAL thickness (blisters, abrasions, pressure ulcers)

coupling for US

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6
Q

Transparent FIlm

A

Polyurethane w/ water resistant

Permeable to O2 and vapors, impermeable to bacteria and water

SUPERFICIAL or PARTIAL thickness
MIN drainage (scalds, abrasions, lacerations)
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7
Q

Most to least Occlusive dressings

A

Hydrocolloids, hydrogels, semipermeable foam, semipermeable film, impregnated gauze, alginates, traditional gauze

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8
Q

Most to least moisture retentive

A

Alginates, semipermeable foam, hydrocolloids, hydrogels, semipermeable films

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9
Q

Wagner Ulcer Grade 0

A

No open lesion, may possess pre ulcerative lesions; healed ulcers, presence of bony deformity

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10
Q

Wagner Ulcer Grade 1

A

Superficla ulcer not involving subcutaneous tissue

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11
Q

Wagner Ulcer Grade 2

A

Deep ulcer with penetration through the subcutaneous tissue, potentially exposing bone, tendon, ligament or joint capsule

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12
Q

Wagner Ulcer Grade 3

A

Deep ulcer with osteitis, abscess or osteomyelitis

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13
Q

Wagner Ulcer Grade 4

A

Gangrene of digit

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14
Q

Wagner Ulcer Grade 5

A

Gangrene of foot requiring disarticulation

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15
Q

Stage 1 pressure ulcer

A

Non blanch-able erythema of intact skin

may indicate deep pressure injury, color changes dont include maroon or purple

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16
Q

Stage 2 pressure ulcer

A

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

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17
Q

Stage 3 pressure ulcer

A

Full thickness skin loss

Adipos is visiable, epibole (Rolled edges) present

Slough and escar may be visable, muscle/tendon/ligament not exposed

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18
Q

Stage 4 pressure ulcer

A

Full thickness skin and tissue loss

Directly exposed or palpable fascia, muscle, tendon, ligament, bone. Slough or eschar may be visible.

Epibole often occur

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19
Q

Unstageable pressure ulcer

A

Obscured full thickness skin and tissue loss

when removed can be a stage 3 or 4

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20
Q

Deep tissue pressure Injury

A

Persistent non blanch-able deep red, maroon, purple discoloration

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21
Q

Phases of healing of wound healing: Inflammatory

A

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
22
Q

Phases of healing: proliferation

A

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
23
Q

Phases of healing: Maturation

A

7 days to 2 years

  • Remodeling phase
  • Granulation and epithelial DIFFERENTIATION begin to appear in the wound bed
  • Hypertrophic scarring in burns affect healing
24
Q

Primary intention

A

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)

25
Q

Secondary Intention

A

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)

26
Q

Tertiary intention

A

Delayed primary intention healing

Wounds at risk for getting complications: sepsis, dehscience

Once cleared of infection or other complications then primary intention occurs

27
Q

Hyperkaratosis

A

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.

28
Q

Serous

A

Presents with clear, light color and a thin, water consistency. Normal in healthy healing

Observed in inflammatory and proliferative phases of healing

29
Q

Sanguineous

A

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

30
Q

Serosanguineous

A

Light red or pink color and a thin, watery consistency

NORMAL in healthy healing wound and observed in inflammatory and proliferative phase of healing

31
Q

Seropurlent

A

Cloudy or opaque, with yellow or tan color and thin and watery consistency

Early warning sign of impending infection and is ABNORMAL

32
Q

Purulent

A

Yellow or green color and a thick, viscous consistency

33
Q

Red - RYB system

A

Pink granulation tissue

Protect wound; maintain moist environment

34
Q

Yellow - RYB system

A

Moist yellow slough

Remove exudate and debris; absorb drainage

35
Q

Black - RYB system

A

Black thick eschar firmly attached

Debride necrotic tissue

36
Q

Dehiscience

A

Separation, rupture, or splitting of a wound by primary intention.

Superficial or involve all layers

37
Q

Dessicated

A

Drying out or dehydrated wound

Poor dressing selection

38
Q

Desquamation

A

peeling, shedding of outer layers

39
Q

Eccymosis

A

Discoloration below intact skin from trauma and blood seeping into the tissues

40
Q

Induration

A

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.

41
Q

Arterial Insufficiency Ulcers

Location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc

A

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

42
Q

AI recommendations

A

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

43
Q

Venous insufficiency ulcers

Location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc

A

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

44
Q

VI recommendations

A

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

45
Q

Neuropathic Ulcers

Location, appearance, exudate, pain, pedal pulses, edema, skin temp, tissue changes, misc

A

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

46
Q

Neuropathic Ulcer recommendations

A

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

47
Q

Pressure ulcers

A

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

48
Q

Pressure ulcer recommendations

A

Reposition every 2 hours

Management of excess moisture

Offload pressure relieving devices

Inspect skin daily

Limit shear, traction and friction forces over fragile skin

49
Q

Superficial Wound

A

Trauma to epidermis in tact

sunburn non blistering

heal normal inflammatory process

50
Q

Partial thickness wound

A

Through epidermis not through dermis

abrasions/blisters/skin tears

heal by re-epitheliazation or epidermal resurfacing

51
Q

Full thickness wound

A

through dermis and to subcutanouse fat. Deeper than 4mm

Heal by secondary intention

52
Q

Subcutaneous Wound

A

Extends through integumentary tissues, deeper structures fat, muscle, tendon,bone, muscle

Heal by secondary intention

NPTE (13 decks)

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