Integumentary System Flashcards
Order of the Phases of Wound Healing
- Hemostasis/Coagulation (immediate)
- Inflammatory phase
- Proliferation/Epithelization phase
- Remodeling phase
Hemostasis/Coagulation (immediate)
- Forms clot & Platelets release PDGF
Inflammatory phase (0-5-10 days)
*Cardinal signs: Calor (heat), Rubor (redness), Tumor (swelling), Dolor (pain)
* Wound may sometimes get stuck here
* NEUTROPHILS and MACROPHAGES working
* Bacteria being eaten by PHAGOCYTOSIS
- re- epithelialization begins 24 hours at the wound borders (though not visually seen till next stage)
Proliferation/Epithelialization phase (3-20 days)
- May last for weeks to months
- GRANULATION tissue is stimulated by macrophages
- Growth factor release stimulates FIBROBLASTS
- Wound bed matrix is established
- ANGIOGENESIS is occurring
- New collagen is being synthesized
- Epithelialization starts to occur
- Later scar formation pattern occurs in basket weave pattern
- Epithelialization - resurfacing and closure
- Keratinocytes close wound
- Melanocytes give color
- Contracture and fibroplasia - tensile strength
- Epithelialization is clinical hallmark of healing
- Contact inhibition can cause epiboly (rolled edges)
Remodeling phase (day 9 on 2 yrs)
- Collagen becomes deposited intro matrix and organized
- After this phase wound has 80% of prewound strength (when first laid down only has ~15% strength)
- Phase can last 1-2 years
Hypertrophic
- Raised, Rigid, Red
- stays within the border
Keloid
- 3 R’s
- Grows out of defined area of injury
- If excised, will grow back
- mature scar: pale, flat, and pliable.
Healing by Intention (3 types)
Primary closure: sutures
- acute wounds with minimal tissue loss.
- smooth clean edges. Reapproximated with sutures, stables, or adhesive
- superficial partial-thickness wounds, such as abrasions or blisters also heal this way.
- minimal scarring and heal quickly
Secondary closure: edges can’t be approximated, granulation tissue filling in, scar tissue eminent
- close on their own without superficial closure
- Wound characteristics: significant tissue loss or necrosis, irregular or nonviable wound margins that can’t be reapproximated, infection or debris.
- Typically associated with pathology (DM, ischemic conditions, pressure damage, or inflammatory damage)
- Granulation fills wound bed
- Requires ongoing wound care
- Larger scar
Tertiary/Delayed primary closure: Combo of primary and secondary closure; Wound left open a few days then surgically closed
- Wounds at risk of developing complications such as sepsis or dehiscence
- Temporarily left open until risk factors have been alleviated…then closed by primary intention methods.
Dermis
- “true skin”
- well vascularized
- elastic, flexible, and tough
- includes sebaceous glands and arrector pili muscles
Epidermis
- avascular epidermis
- most superficial layer of skin
Where are nerve endings found on the skin?
Hypodermis
Which structure in the epidermis serves as a barrier against fluid, electrolyte, and chemical loss?
stratum corneum
The stratum corneum in the epidermis functions for protection from trauma and microbes, and serves as a barrier to prevent fluid, electrolyte, and chemical loss. The primary function of basal cells, Langerhans cells, and keratinocytes is for epidermal reproduction, immunity, and keratin synthesis respectively.
Which of the following inflammatory mediators is responsible for causing pain in an acute wound?
Prostaglandins
Prostaglandins promote local vasodilation that increases the permeability of local capillaries and induce pain. Prostaglandins are a part of the inflammation cascade following tissue injury.
The process by which epithelial cells die and produce a protective outer layer is called:
Keratinization
Keratinization refers to the development of or conversion to keratin. Keratinocytes are cells located in the epidermal layer that produce keratin, a strong protein that makes up the rigid structure of the skin, hair, and nails.
Arterial Insufficiency Ulcers General Recommendations for treatment
(What to do and not do)
Due to inadequate circulation of oxygenated blood (ischemia)… typically from atherosclerosis.
- Rest
- Limb protection
- Risk Reduction education
- Inspect legs and feet daily
- Avoid unnecessary leg elevation
- Avoid using heating pads or soaking feet in hot water
- wear appropriately sized shoes with clean, seamless socks
Venous Insufficiency Ulcers General Recommendations for treatment
from venous insufficiency occur secondary to impaired functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration.
- limb protection
- risk reduction education
- inspect legs and feet daily
- compression to control edema
- elevate legs above the heart when resting or sleeping
- attempt active exercise including frequent ROM
- wear appropriately sized shoes with clean, seamless socks
Neuropathic Ulcers General Recommendations for treatment
secondary complication associated with ischemia and neuropathy. Often associated with DM.
- limb protection
- risk reduction education
- inspect legs and feet daily
- inspect footwear for debris prior to donning
- wear appropriately sized off-loading footwear with clean, cushioned, seamless socks
Pressure Ulcers General Recommendations for treatment
prolonged or sustained pressure on tissue at levels greater than that of capillary pressure.
- repositioning every 2 hours in bed
- management of excess moisture
- off-loading with pressure relieving devices
- inspect skin daily for signs of pressure damage
- limit shear, traction, and fraction forces over fragile skin
Characteristics of Arterial Insufficiency Ulcers
- lower 1/3 of leg, toes, web spaces (distal toes, dorsal foot, lateral malleolus)
- Smooth edges, well defined (lacks granulation tissue; tend to deep)
- Minimal exudate
- Severe pain
- Diminished or absent pulses
- Normal edema
- Decreased skin temp
- Shiny, hair loss, yellow nails
- leg elevates increases pain
Characteristics of Venous Insufficiency Ulcers
- Proximal to medial malleolus
- Irregular shape and shallow
- Moderate to heavy exudate (wet wound)
- Mild to moderate pain
- Normal pulses
- Increased edema
- Normal skin temp
- flaking, dry skin; brownish discoloration (hemosiderin staining)
- Leg elevation lessens pain
What is a superficial wound and its characteristics
- A superficial wound causes trauma to the skin with the epidermis remaining intact,
- Such as with a non-blistering sunburn.
- A superficial wound will typically heal as part of the inflammatory process.
Partial-thickness wound characteristics
- A partial-thickness wound extends through the epidermis and possibly into, but not through, the dermis.
- Examples include abrasions, blisters, and skin tears.
- Typically heal by re-epithelialization or epidermal resurfacing depending on the depth of injury.
Full-thickness wound characteristics
- Wound extends through the dermis into deeper structures such as subcutaneous fat.
- Wounds deeper than 4 millimeters are typically considered full-thickness and heal by secondary intention.
Subcutaneous wound characteristics
- Extend through integumentary tissues and involve deeper structures such as subcutaneous fat, muscle, tendon or bone.
- Subcutaneous wounds typically require healing by secondary intention.
What are the stages of pressure injury staging?
Stage 1
Stage 2
Stage 3
Stage 4
Deep Tissue Injury
Unstageable
Stage 1 Pressure Ulcer characteristics
Non-blanchable erythema of intact skin
* Intact skin
- non-blanchable erythema
- Sensation, temperature, or firmness may precede visual changes
Stage 2 Pressure Ulcer characteristics
Partial-thickness skin loss with exposed dermis
- exposed dermis, serum filled blister, not deep
*pink/red moist wound bed.
* intact or ruptured serum-filled blister
* Adipose is not visible and deeper tissue are not visible
Stage 3 Pressure Ulcer characteristics
Full-thickness skin loss
- Adipose tissue is visible and granulation tissue or epibole are often present
- Slough and/or eschar may be visible
- Slough is an automatic stage 3
- Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed
Stage 4 Pressure Ulcer characteristics
Full thickness skin and tissue loss
- Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in ulcer
- Major pressure injury
- Slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury
Unstageable Pressure Injury Pressure Ulcer characteristics
Obscured full-thickness skin and tissue loss
- Full thickness skin and tissue loss
- Extent cannot be confirmed because it is obscured by slough or eschar
- Will reveal stage 3 or 4
- Stable eschar on the heel or ischemic limb should not be softened or removed
Deep Tissue Injury Pressure Ulcer characteristics
- Intact or non-intact skin
- Results from intense and/or prolonged pressure and shear forces at bone-muscle interface
- May evolve rapidly
- May resolve without tissue loss
Wagner Ulcer Grade Classification Scale
0 - No open lesion, but may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity
1 - Superficial ulcer not involving subcutaneous tissue
2 - Deep ulcer with penetration through the subcutaneous tissue; potentially exposing bone, tendon, ligament or joint capsule
3 - Deep ulcer with osteitis, abscess or osteomyelitis
4 - Gangrene of digit
5 - Gangrene of foot requiring disarticulation
Used to classify diabetic foot ulcers
Thermal burn:
Caused by conduction or convection.
Examples include burns resulting from contact with a hot liquid, fire or steam.
Electrical burn:
- Caused by the passage of electrical current through the body.
- Typically there is an entrance and an exit wound.
- Complications can include cardiac arrhythmias, respiratory arrest, renal failure, neurological damage, and fractures.
- Example: a lightning strike is an example of an electrical burn
Chemical burn:
- Occurs when certain chemical compounds come in contact with the body.
- The reaction will continue until the chemical compound is diluted at the site of contact.
- Compounds that cause chemical burns include sulfuric acid, lye, hydrochloric acid, and gasoline.
Radiation burn:
- Occurs most commonly with exposure to external beam radiation therapy.
- DNA is altered in exposed tissues and ischemic injury may be irreversible.
- Complications may include severe blistering and desquamation, non-healing wounds, tissue fibrosis, permanent discoloration, and new malignancies.
Zone of coagulation:
The area of the burn that received the most severe injury with irreversible cell damage.
Zone of stasis:
The area of less severe injury that possesses reversible damage and surrounds the zone of coagulation.
Zone of hyperemia:
The area surrounding the zone of stasis that presents with inflammation, but will fully recover without any intervention or permanent damage.
Superficial burn:
- A superficial burn involves only the outer epidermis.
- The involved area may be red with slight edema.
- Healing occurs without peeling or evidence of scarring in two to five days.
- Goal: provide a wound environment which promotes re-epithelialization. (can be through moisturizing cream)
Superficial partial-thickness burn:
- A superficial partial-thickness burn involves the epidermis and the upper portion of the dermis.
- The involved area may be extremely painful and exhibit blisters.
- Healing occurs with minimal to no scarring in 5-21 days.
- Goal: prepare wound for primary healing. Such as wound cleansing and debridement of the larger, more fragile blisters.
Deep partial-thickness burn:
- Involves complete destruction of the epidermis and the majority of the dermis.
- May appear to be discolored with broken blisters and edema.
- Damage to nerve endings may result in only moderate levels of pain.
- Hypertrophic or keloid scarring may occur.
In the absence of infection, - Healing will occur in 21-35 days.
- Goal: prepare wound for primary healing. Such as wound cleansing and debridement of the larger, more fragile blisters
Full-thickness burn:
- Complete destruction of the epidermis and dermis along with partial damage to the subcutaneous fat layer.
- Presents with eschar formation and minimal pain.
- Require grafts and are susceptible to infection.
- Healing time varies significantly with smaller areas healing in a matter of weeks, with or without grafting, and larger areas requiring grafting and potentially months to heal.
- Goal for PT: prepare wound for sx by controlling infection (by antimicrobial topical agents and proper wound cleansing). Treated in the operating room with surgical incision and skin grafting.
Subdermal burn:
- Complete destruction of the epidermis, dermis, and subcutaneous tissue.
- Involve muscle and bone and as a result, often require multiple surgical interventions and extensive healing time.
Serous Exudate
- clear, light color
- thin, watery consistency
- normal in healthy healing wound
- in inflammatory and proliferative phase of healing
Sanguineous Exudate
- red color
- thin, watery consistency
- pressure of blood that may become brown if allowed to dehydrate
- indicative of new blood vessel growth or disruption of blood vessels
Serosanguineous Exudate
- light red or pink color (PTFE says light brown)
- thin, watery consistency
- normal in healthy healing wound
- inflammatory and proliferative phase
Seropurulent exudate
- cloudy or opaque
- yellow or tan color and thin, watery consistency.
- early warning sign of impending infection
- always abnormal
Purulent
- yellow or green color
- thick, viscous consistency
- indicator of wound infection
- always abnormal
Sharps Debridement
- Excision of nonviable tissue using scalpel, forceps, or scissors
- Indicated for removing eschar, loose slough, or adherent fibrin
- for large amounts of thick, adherent, necrotic tissue.
- may also be used with cellulitis or sepsis
- PT can perform
Wet to Dry
- Type of mechanical debridement; Nonselective
- Removal of necrotic tissue using some source of mechanical energy (let moistened gauze dry and then is removed
- For moderate amounts of exudate and necrotic tissue
- Indication when risk of harming healthy tissue doesn’t exceed benefit of removal of necrotic material
- May dry out wound bed, often may be more costly and expensive
- Removal of dry dressing from granulation can cause bleeding and be extremely painful
Autolytic Debridement
- Use of moisture-retentive dressing to facilitate body’s own enzymes to breakdown tissue. (Uses the body’s own endogenous mechanisms to facilitate healing)
- Conservative
- Not for use with infected wounds, no occlusion
- Hydrogels, hydrocolloids, alginates, transparent films
- Selective
- moist wound environment that rehydrates necrotic tissue and eschar that facilitates enzymatic digestion of the nonviable tissues.
- takes longer period of time to heal
