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
Enzymatic Debridement
- Selective and uses topical enzymes to emulsify dead, nonviable tissue
- Collagenases, fibriolysins, and proteolytic enzymes
- Generally slower than sharps, faster than autolytic
- Less traumatic and painful
Hydrotherapy for non-selective debridement
- softens and loosens adherent necrotic tissue
- side effects: maceration of viable tissue, edema from dependent positioning, and systemic effects such as hypotension
Negative Pressure Wound Therapy (NPWT)
Indications
* Chronic or acute wounds which cannot be closed by primary intention (dehisced surgical incisions, full-thickness wounds, partial-thickness burns, heavily draining granular wounds, flaps, grafts, and most ulcer types.
Contraindications
* Malignancy within the wound, insufficient vascularity to sustain wound healing, large amounts of necrotic tissue with eschar present, untreated osteomyelitis, fistulas to organs or body cavities, exposed arteries or veins, and uncontrolled pain.
Advantages
* Provides management of wound drainage
* Maintains a moist wound environment
* Decreases interstitial edema
* Decreases bacterial colonization
* Increases capillary blood flow
* Increases granular tissue formation
* Enhances epithelial cell migration
Disadvantages
* Requires special supplies and training
* Treatment can be painful
* Not reimbursed in acute or long-term care settings
Hyperbaric Oxygen
- Inhalation of 100% oxygen at pressures greater than one atmosphere.
- delivered in a closed chamber typically at pressures 2-3x that of the atmosphere – effectively reducing edema and hyperoxygenating tissues.
Indications
* Osteomyelitis, diabetic wounds, crush injuries, compartment syndromes, necrotizing soft tissue infection, thermal burns, radiation necrosis, and compromised flaps and grafts.
Contraindications
* Terminal illness, untreated pneumothorax, active malignancy, pregnancy, seizure disorder, emphysema, and use of certain chemotherapy agents.
Advantages
* Antibiotic effects
* Stimulation of fibroblast production and collagen synthesis
* Stimulation of growth factor release and epithelialization
Disadvantages
* Specialized equipment is not widely available
* Cannot be used with active malignancy
Growth Factors
- Used in wound healing are derived from naturally occurring protein factors.
- Facilitate healing by stimulating the activity of specific cell types (e.g, neutrophils, endothelial cells, fibroblasts).
- Only a limited number of growth factors have been approved by the Food and Drug Administration for topical wound healing applications.
Indications
* Neuropathic ulcers extending into or through subcutaneous tissue with adequate circulation to sustain wound healing.
Contraindications
* Wounds closed by primary intention, patients with known hypersensitivity to any component of the product or a history of neoplasm at the application site.
Advantages:
* Adjunct to promote wound healing environment
* Increases growth rate of new tissue
* Promotes cell division
Disadvantages
* Costly
* Poor reimbursement
* Additional research is needed
* Secondary dressing required
* Requires refrigeration
* Limited approval by the FDA
Alginates Dressing
- derived from a seaweed extraction (calcium salt component of alginic acid.)
- Alginates are highly absorptive, but are also highly permeable and non-occlusive.
- Require a secondary dressing.
- Act as a hemostat and create a hydrophilic gel through the interaction of calcium ions in the dressing and sodium ions in the wound exudate.
Indications
* Partial or full-thickness draining wounds such as pressure or venous insufficiency ulcers.
* Often used on infected wounds due to the likelihood of excessive drainage.
Advantages
* High absorptive capacity
* Enables autolytic debridement
* Offers protection from microbial contamination
Can be used on infected or non-infected wounds
* Non-adhering to wound
Disadvantages
* May require frequent dressing changes based on level of exudate
* Requires a secondary dressing
* Cannot be used on wounds with an exposed tendon, joint capsule or bone
Foam Dressing
- Comprised of a hydrophilic polyurethane base that contacts the wound surface and a hydrophobic outer layer.
- Allow exudate to be absorbed into the foam through the hydrophilic layer.
- Most commonly available in sheets or pads with varying degrees of thickness.
Indications
* Used to provide protection and absorption over partial and full-thickness wounds with varying levels of exudate.
* Also be used as secondary dressings over amorphous hydrogels.
Advantages
* Provides a moist environment for wound healing
* Available in adhesive and non-adhesive forms
* Provides prophylactic protection and cushioning
* Encourages autolytic debridement
* Provides moderate absorption
Disadvantages
* May tend to roll in areas of excessive friction
* Adhesive form may traumatize periwound area upon removal
* Lack of transparency makes inspection of wound difficult
Gauze Dressing
- Yarn or thread and are the most readily available dressing used in inpatient environments.
- Impregnated gauze: various materials such as petrolatum, zinc or antimicrobials have been added.
Indications
* Infected or non-infected wounds of any size.
* Wet-to-wet, wet-to-moist or wet-to-dry debridement.
Advantages
* Readily available and cost effective short-term dressings
* Can be used alone or in combination with other dressings and
topical agents
* Can modify number of layers to accommodate for changing wound status
* Can be used on infected or non-infected wounds
Disadvantages
* Has a tendency to adhere to the wound bed traumatizing viable tissue on removal
* Highly permeable
* Requires frequent dressing changes
* Prolonged use decreases cost effectiveness
* Increased infection rate compared to occlusive dressings
Hydrocolloids dressing
- Consist of gel-forming polymers (e.g., carboxymethylcellulose, gelatin, pectin) backed by a strong film or foam adhesive.
- Anchors to the intact surrounding skin (not the wound).
- Absorb exudate by swelling into a gel-like mass and vary in permeability, thickness, and transparency.
Indications
* Partial and full-thickness wounds. The dressings can be used effectively with granular or necrotic wounds.
Advantages
* Provides a moist environment for wound healing
* Enables autolytic debridement
* Offers protection from microbial contamination
* Provides moderate absorption
* Does not require a secondary dressing
* Provides a waterproof surface
Disadvantages
* May traumatize surrounding intact skin upon removal
* May tend to roll in areas of excessive friction
* Cannot be used on infected wounds
Hydrogels dressing
- Varying amounts of water and gel-forming materials such as glycerin.
Indications
* Moisture retentive and commonly used on superficial and partial-thickness wounds (e.g., abrasions, blisters, pressure ulcers) that have minimal drainage.
Advantages
* Provides a moist environment for wound healing
* Enables autolytic debridement
* May reduce pressure and diminish pain
* Can be used as a coupling agent for ultrasound
* Minimally adheres to wound
* Some products have absorptive properties
Disadvantages
* Potential for dressings to dehydrate
* Cannot be used on wounds with significant drainage
* Typically REQUIRE a SECONDARY DRESSING
Transparent Film dressing
- Water-resistant adhesives.
- Permeable to vapor and oxygen, but are largely impermeabe to bacteria and water.
- Highly elastic, conform to a variety of body contours, and allow easy visual inspection of the wound since they are transparent.
Indications
* Superficial or partial-thickness wounds with minimal drainage (e.g., scalds, abrasions, lacerations).
Advantages
* Provides a moist environment for wound healing
* Enables autolytic debridement
* Allows visualization of the wound
* Resistant to shearing and frictional forces
* Cost effective over time
Disadvantages
* Excessive exudate accumulation can result in periwound
maceration
* Adhesive may traumatize periwound area upon removal
* Cannot be used on infected wounds
Cellulitis
- Fast spreading inflammation that occurs as a result of a bacterial infection of the skin and connective tissues.
*Can develop anywhere under the skin, but will typically affect the extremities.
Etiology
- Cellulitis is caused by particular bacterial infections including streptococci or staphylococci.
- Predisposing factors to cellulitis include an increased age, immunosuppression (from meds or medical conditions (HIV or leukemia), trauma, the presence of wounds or venous insufficiency.
- DM may develop cellulitis without identifiable cause
Signs and Symptoms
- Symptoms may include localized redness that may spread quickly, warmth, weeping, and serous drainage, tenderness to palpation, edema that progressively worsens (red streaks leading away from primary site of infection
- May develop systemic signs if condition worsens: chills, fever, and malaise.
Treatment
- A patient with suspected cellulitis should be immediately referred to a physician for further assessment.
- Requires pharmacological intervention using systemic antibiotics.
- Differential diagnosis should attempt to rule out deep vein thrombosis and contact dermatitis.
- Cellulitis can lead to sepsis or gangrene if not properly treated.
- Repeated cellulitis infection s and the associated edema can cause permanent damage to the lymphatic system.
Contact Dermatitis
- Superficial irritation of the skin resulting from localized irritation (e.g., poison ivy, latex, soap, jewelry sensitivity).
- Acute or chronic based on exposure to the precipitating agent.
Etiology
- occurs with exposure to mechanical, chemical, environmental or biological agents. Nickel, rubber, latex, and topical antibiotics are common precipitating agents.
Signs and Symptoms
- Patients experience intense itching, burning, and red skin in areas corresponding to the location of the topical irritation.
- Edema may also occur in the area of sensitivity and symptoms can expand beyond the initial point of topical
irritation.
Treatment
- The focus of treatment should be on identifying and removing the source of irritation.
- Topical steroid application is commonly employed. Acute lesions should resolve with treatment once exposure to the external irritant has been removed.
Eczema
- aka dermatitis
- describe a group of disorders that cause chronic skin inflammation typically due to an immune system abnormality, allergic reaction or external irritant.
Etiology
- based on the particular form of the disorder.
- Infants and children are at higher risk for eczema, however, many outgrow the condition with age.
- The geriatric population is also at an increased risk for many forms of eczema.
Signs and Symptoms
- Red or brown-gray, itchy, lichenified skin plaques that may be exacerbated by some topical agents such as soaps and lotions.
- younger: frequently experience oozing and crusting of the patchy areas of irritation.
Treatment -
Pharmacological interventions are variable ranging from topical or oral corticosteroids to oral antibiotics and antihistamines. Cold compresses and other modalities may assist with reducing the itching. Stress management techniques and avoidance of extreme temperatures should be employed to avoid potential exacerbations of the condition.
Gangrene (Dry)
- “dry” when there is a loss of vascular supply resulting in local tissue death.
- Fingers, toes, and limbs are most often affected.
- hardened tissue is not painful, however, there may be significant pain at the line of demarcation.
- Typically develops slowly and in some cases results in auto-amputation.
Etiology
- Occurs most commonly in blood vessel disease, such as DM or atherosclerosis.
- Can progress to wet gangrene if infection occurs.
Signs and Symptoms
- Dark brown or black nonviable tissue that eventually becomes a hardened mass (mummified). - The patient may complain of cold or numb skin and they may present with pain.
Treatment
- Serious medical condition and requires immediate medical intervention. Depending on the severity, gangrene is treated by pharmacological intervention, surgery, and hyperbaric oxygen therapy.
Gangrene (Wet)
- associated bacterial infection in the affected tissue.
- may develop as a complication of an infected untreated wound.
- Swelling resulting from the bacterial infection causes a sudden stoppage of blood flow.
Etiology
- Can develop after a severe burn, frostbite or injury and requires immediate treatment since it tends to spread very quickly and can be fatal.
- Cessation of blood flow that starts a chain of events including invasion by bacteria at the affected site.
Signs and Symptoms
- swelling and pain at the site of infection, change in skin color from red to brown to black, blisters that produce pus, fever, and general malaise
Treatment
- serious medical condition and requires immediate medical intervention. Surgical debridement of the gangrene and intravenous antibiotic treatment are typical interventions for wet gangrene. Depending on the severity, gangrene is treated by pharmacological intervention, surgery, and hyperbaric oxygen therapy.
Onychomycosis
- A fungal infection that primarily affects the toenails and nailbeds.
- divided into subtypes, but are typically medically treated in a similar fashion.
Etiology
- Acquiring a fungal infection can be a fairly common occurrence.
- Risk factors include manicures and pedicures with unsterile utensils, possessing nail injuries or deformities, excess skin moisture, wearing closed toe shoes, and an impaired immune response.
Signs and Symptoms
- yellow or brown nail discoloration; hyperkeratosis and hypertrophy of the nail causing it to partially detach from the nailbed
Treatment
- Manual debridement of the nail and topical antifungal medications are primary interventions. Fungal infections may return to the nailbeds and in some cases, the nails may have permanent
damage.
Psoriasis - Plaque
- chronic autoimmune disease of the skin
- most common of the five types of psoriasis.
- T cells trigger Inflammation within the skin and produce an accelerated rate of skin cell growth. The skin cells accumulate in raised red patches on the surface of the skin.
Etiology
- Some patients have a genetic predisposition to plaque psoriasis.
- Other factors may trigger psoriasis, such as injury to the skin, insufficient or excess sunlight, stress, excessive alcohol, HIV infection, smoking, and certain medications.
Signs and Symptoms
- The primary symptom is red raised blotches that typically present in a bilateral fashion for example over both knees or elbows.
- These plaques can appear anywhere on the body and will tend to itch and flake.
- Complications can include arthritis, pain, severe itching, secondary skin infections, and side effects secondary to pharmacological interventions.
Treatment
- primary goal to control the symptoms and prevent secondary infection.
- Treatment varies widely from topical applications to systemic medications and phototherapy.
- Plaque psoriasis is a life-long condition that can be effectively managed and controlled through the various stages and exacerbations.
Tinea Pedis
- aka athlete’s foot,
- superficial fungal infection which causes epidermal thickening and a scaly skin appearance. * This fungus is opportunistic and will rapidly multiply in a warm and moist environment (e.g., between the toes).
Etiology
- Risk factors include wearing closed toe shoes that don’t allow airflow, prolonged periods of moisture or wetness, excessive sweating, and possessing small nail or skin abrasions. This infection is contagious through direct contact or when making contact with a surface containing the tinea pedis infection.
Signs and Symptoms
- itching, redness, peeling skin between the toes, pain, odor, and in more severe cases breaks in skin continuity
Treatment
- Pharmacological intervention includes topical or oral antibiotics depending on the severity of symptoms. Tinea pedis may persist or recur and more long-term management may be required. Prevention includes thorough drying of the feet when bathing or swimming, wearing sandals around public pools or showers, changing socks frequently, proper hygiene, and avoiding shoe wear that creates a moist environment.
Herpes Zoster
- varicella-zoster virus = children
herpes zoster (shingles) = adults - can lie dormant for years and is highly contagious when it isn’t dormant
- Reactivation can occur when immune system has been weakened
- S&S
- blistered rash will appear on skin surface…but also on internal structures such as organ surfaces, mouth, and inner eye
- itching or burning sensation (from attack on nerves)
- painful blister rash
- fever, body aches, chills, fatigue
- blisters break open and drain
- post-herpatic neuralgia due to scarring/destruction of nerve tissue is most common complication
- Other complication: vision loss, balance deficits, or facial paralysis
Which burn classification would heal without peeling or presence of scarring within 2-5 days?
Superficial
Which type of burn is typically present with eschar formation and minimal pain to the involved area?
Full-thickness
Which burn often requires multiple surgical interventions and extensive healing time?
Subdermal burns
Which type of burn may cause respiratory arrest or renal failure?
Electrical
Which burn classification is most likely to result in hypertrophic and keloid scarring after the healing process is complete?
Deep partial-thickness
Which of the following zones of injury corresponds with the most severe area of injury at a burn site that sustained irreversible cell damage?
zone of coagulation
There are three zones of injury at the site of a burn. The centermost area is classified as the zone of coagulation. This area corresponds with the most severe injury with irreversible cell damage. The zone of stasis is circumferentially outside of the zone of coagulation and corresponds to the area of the burn that sustained reversible damage. The outermost area of a burn is termed the zone of hyperemia and is characterized by inflammation.
What is the primary cause of burns in adolescents and adults?
hot liquids
Contact with hot liquids is the primary cause of burns in adolescent and adults. Men and boys between the ages of 16 and 40 have the highest incidence of injury.
Which burn classification would most likely affect the pH of systemic tissue?
Chemical
Chemical burns can significantly alter systemic tissue pH and metabolism. These changes can create potentially serious pulmonary and metabolic complications. The severity of the complications is heavily influenced by the concentration of the chemical, duration of contact, and mechanism of action.
A burn that presents with significant pain and blistering is most likely to be classified as a:
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.
What are the types of Selective debridement?
Sharps
Enzymatic
Autolytic
What are the types of non-selective debridement?
Wet-to-dry
Wound Irrigation
Hydrotherapy
Surgery
What refers to the use of the body’s own mechanism to remove nonviable tissue?
Autolytic debridement
Which would most likely to be used as a process to soften and loosen adherent necrotic tissue?
Enzymatic debridement
Autolytic debridement
Hydrotherapy
Wound irrigation
Hydrotherapy
Which form of wound debridement converts a chronic wound into an acute wound using specific instruments, decreasing the surface bacterial burden, and removing senescent cells?
sharp
Sharp debridement is a surgical procedure that uses scissors, scalpels and other sharp instruments to cut away or remove infected tissue. Sharp debridement improves the wound’s appearance and promotes enhanced healing by removing devitalized tissue.
What does occlusive dressing mean?
type of dressing that is completely impermeable
Which of the following would typically be the dressing of choice to treat a stage 1 or 2 pressure injury?
Transparent film
Transparent film dressings such as Tegaderm are dressings of choice for stage 1 and 2 pressure injuries with blister formation over bony prominences. This type of dressing should not be used on draining or infected wounds.
Which of these wound dressings can be utilized to treat an infected pressure injury?
Calcium Alginates
Calcium alginates are typically used on partial or full-thickness draining wounds such as pressure or venous insufficiency ulcers. Alginates are often used on infected wounds due to the likelihood of excessive drainage.
Match the level of injury to which level of skin is injured
Superficial = Epidermis
Superficial partial-thickness = papillary dermis
Deep partial-thickness = Reticular dermis
Full-thickness = Entire dermis
Common method of grading pressure injuries
Braden Scale
What is the common complication of herpes zoster
Post herpetic neuralgia
The rubor of dependency test is used to assess the presence of which condition?
arterial insufficiency
The rubor of dependency test is used to assess for the presence of arterial insufficiency. The therapist elevates the patient’s leg with the patient in supine and notes the change in color of the lower extremity. A patient with arterial insufficiency will experience a rapid loss of the normal pinkish color of the skin, and it will take a prolonged period of time (i.e., greater than 30 seconds) for the color to return when the leg is returned to the starting position.
Which of the following would be considered an appropriate compression pressure for use with a patient with a venous wound?
10mmHg
20 mmHg
30 mmHg
40 mmHg
40 mm Hg
Short stretch bandaging with high working pressure and low resting pressure help to facilitate the effects of the calf muscle pump during activity. Pressure of 40 mm Hg has been suggested as an acceptable guideline for patients with venous wounds.
Which of the following interventions should be avoided when treating a patient with an arterial insufficiency ulcer on their lower leg?
compression dressings
Compression dressings can further impede the circulation of a patient with an arterial insufficiency ulcer. There is no restriction to therapeutic exercises and gait training as long as pressure is not applied to the wound. Applying a hot pack to a more proximal segment will cause vasodilation and can help circulation at more distal segments
What clinical term describes a group of conditions causing weeping of the skin and pruritus?
eczema
Eczema is a term for a group of medical conditions that cause the skin to become inflamed or irritated. The condition is characterized by red or brown-gray, itchy, lichenified skin plaques that may be exacerbated by topical agents such as soaps and lotions. The most common type of eczema is known as atopic dermatitis or atopic eczema.
Arterial Insufficiency Ulcer information
- Ulcer is caused by inadequate perfusion of oxygenated blood to affected tissue. —-leads to cell death and necrosis.
- typically from atherosclerosis or arterial embolism
- Peripheral artery disease (PAD): narrowing of arterial vessels that impedes delivery of oxygen to tissues
- Limb-related pain is most commonly positional, occurring with the limb is in a non-dependent position or with activity that results with intermittent claudication
- Characteristics: lower 1/3 of leg, lateral malleolus, dorsum of foot, toes, smooth and defined wound edges, minimal exudate, skin is cool to touch, thin, shiny, and hairless. Diminished distal pulses
Neuropathic Ulcer
- typically from peripheral neuropathy, atherosclerotic changes, and pressure,
- most frequently in the diabetic population
- Motor Neuropathy: cause weakness of the intrinsic foot m allowing the forefoot to splay during the WB and altering the fit of footwear. Decreased coordination, loss of protection sensation.
- Common sites: heel, tips of prominent toes, tips of hammer toes, plantar surface of the metatarsal heads, dorsal aspect of hammer toes, and bunions.
- Wound characteristics:
- Well-defined oval or round shape
- Granular tissue with little evidence of necrosis
- Exudate is minimal
- Pain is minimal
- Skin is shiny, dry, and inelastic
- Pulses is diminished or absent
- ABI measures may be unreliable especially for pts with DM who are likely to develop vessel rigidity.
- Treatment
- Pharmaceutical interventions: PDGF, antimicrobial antibiotics
- Surgical management: debridement for wounds with heavy necrosis, grafting for non-healing wounds.
- Activity restrictions
- Specialized footwear
- PT: skin protection, moisturizers, skin inspection, and wound healing interventions
Venous Insufficiency Ulcer
- From venous hypertension either idiopathically or secondary to valve incompetence or peripheral impedance
- Formation of ulcer from increased tissue pressure that decreases skin resilience and endothelial damage that allows enzyme and free radical leakage into tissue
- Location/Characteristics
- medial surface of lower leg in between mid-calf and medial malleolus
- large in area and shallower in depth
- irregular borders
- Granulation tissues
- Moist layer of yellow-white slough
- serous or serosanguineous exudate (moderate to heavy)
- Stasis dermatitis
- Skin dry, flaky appearance
- Hemosiderin staining (ruddy, brownish skin discoloration)
- Distal LE pulses are intact
- Mild pain complaints
- increased tissue tension caused by edema
- pain is typically relieved by elevation or compression garment
- Treatment
- bypass, stent, grafting, valve repair
- graded compression (garments, bandaging, Unna boot)
- typically heal by secondary intention
Which position of the shoulder would be the most appropriate to prevent a contracture following a burn to the anterior chest?
abduction, flexion, lateral rotation
The anticipated deformity from a burn to the anterior chest or axilla is shoulder adduction, extension and medial rotation. Splinting that places the shoulder in a position that is opposite the anticipated contracture would be the most appropriate
Which position of the hip would be the most appropriate to prevent a contracture following a burn to the anterior hip?
hip extension and abduction
The anticipated deformity resulting from a burn to the anterior hip would be hip flexion and adduction. Anterior hip spica casts and abductions splints are common interventions to prevent and manage contraction.
An airplane splint applied following a burn would most likely be used to avoid a contracture affecting the:
shoulder
An airplane splint is used to immobilize a shoulder during healing from an injury, surgery or burn. The splint maintains the arm in an abducted position at or below shoulder level with the elbow typically flexed.
What factors influence wound healing?
- Age
- Co-morbidities
- Edema
- Harsh or Inappropriate wound care
- Infection
- Lifestyle
- Medication
- Obesity
What score on the Braden scale would most warrant initiation of a pressure injury prevention program?
16
It is recommended that individuals who score an 18 or less on the Braden scale be placed on a pressure injury prevention program. The scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Each section of assessment is scored from one to four with the exception of friction and shear, which is scored one to three. The maximum score on the Braden scale is 23.
A percussion test can help to identify which of the following risk factors for developing skin ulceration?
venous insufficiency
A percussion test assesses the valves of the saphenous vein by percussing a distal segment of the vein while palpating a proximal segment. If the proximal hand senses blood movement, the valves are not functioning properly. Venous insufficiency is a major risk factor for developing skin breakdown
Rule of Nines (Adults)
Head and neck = 9%
Trunk = 36% (Anterior 18%/ Posterior 18%)
Arm = 9% (each) (Anterior 4.5%/Posterior 4.5%)
Genital Region = 1%
LE = 18% (each LE) (Anterior 9%/Posterior 9%)
Anticipated Burn Deformities of Anterior neck
- Anticipated deformity: flexion with possible lateral flexion
- Splinting: soft collar, molded collar, Philadelphia collar
Anticipated Burn Deformities of Anterior chest and axilla
- Anticipated Deformity: Shoulder adduction, extension, and medial rotation
- Splint: Axillary or airplane splint, shoulder abduction brace
Anticipated Burn Deformities of Elbow
- Anticipated Deformity: Flexion and pronation
- Splint: Gutter splint, conforming splint, three-point splint, air splint
Anticipated Burn Deformities of Hand and Wrist
- Anticipated deformity:
- Extension or hyperextension of the MCP joints;
- Flexion of the IP joints;
- Adduction and flexion of the thumb;
- Flexion of the wrist
- Splint:
- Wrist splint
- Thumb or spica splint
- Palmar or dorsal extension splint
Anticipated Burn Deformities of Hip
- Anticipated deformity: Flexion and adduction
- Splint: Anterior hip spica, abduction splint
Anticipated Burn Deformities of Knee
- Anticipated deformity: Flexion
- Splint: Conforming splint, three-point splint, air splint
Anticipated Burn Deformities of Ankle
- Anticipated deformity: Plantar flexion
- Splint:
- Posterior foot drop splint
- Posterior ankle conforming splint
- Anterior ankle conforming splint
According to the rule of nines, what percentage of the total body surface area would be allocated to the posterior surface of the bilateral legs and feet?
18%
The rule of nines is not appropriate to assess which type of burn?
superficial
The “rule of nines” is commonly utilized to assess the percentage of the body surface affected by partial thickness and full thickness burns
According to the rule of nines, a burn affecting the anterior right leg and foot would constitute what percentage of the total body surface area?
9%
According to the rule of nines, a burn affecting the posterior trunk and posterior left arm, forearm and hand, would constitute what percentage of the total body surface area?
22.5%
According to the rule of nines, at what age does a child reach the same body proportions as an adult?
9
A child under one year has 9% taken from the lower extremities and added to the head and neck region. Each year of life, 1% is distributed back to the lower extremities until the age of nine when the head is considered to be the same proportion as an adult.
When using the rule of nines for a young child, which part of the body makes up a larger percentage as compared to an adult?
Head and neck
According to the rule of nines, 36% of the body is made up of the trunk, 18% for each lower extremity, 9% for each upper extremity, 9% for the head and neck, and 1% for the genitals. When using this method for a child, the head and neck make up 18% of the body and the lower extremities each make up 14%.
Using the rule of nines, what percentage of the body is affected if there is a burn to the posterior trunk, posterior left lower extremity, and the entire left upper extremity?
36.0%
The rule of nines is a method used to approximate the percentage of the body affected by a burn. The posterior trunk constitutes 18% of the total body surface area, the posterior portion of the left lower extremity constitutes 9%, and the entire left upper extremity constitutes 9% (4.5% for each side). 18%+9%+9% = 36%
According to the rule of nines, what percentage of the body would be affected by burns covering the anterior surface of the arms and legs bilaterally?
27.0%
According to the rule of nines, each arm is approximately 9% of the total body surface area and each leg is 18%. Therefore the bilateral, anterior surfaces of all four extremities would represent 27.0% of the total body surface area.
What percentage of the total body surface area would be affected with a burn that covers the anterior portions of the bilateral lower extremities and the anterior portion of the right arm?
22.5%
According to the rule of nines, the total surface area of the anterior portions of the bilateral lower extremities is 18% and the total surface area of the anterior portion of the right arm is 4.5%. The total surface area affected by the burn is equivalent to 22.5%.
Pt has significant facial burns after a workplace explosion. Which finding would MOST likely be associated with burn-related alterations in cell permeability and microcirculation?
1.Hypertrophic scarring
2.Eschar
3.Edema
4.Keloid scarring
- Severe edema is the most common occurrence.
Severe burns cause protein loss from burned tissues and increased cell membrane permeability. Both factors contribute to alterations in tissue microcirculation resulting in significant edema formation in the interstitial spaces. - Hypertrophic or keloid scarring: associated with an imbalance of collagen lysis and synthesis during the healing process. During the remodeling phase (so not while in acute care)
- Eschar refers to necrotic tissue which is typically brown or black in color and thickly textured. Eschar may be observed while a patient with significant burns is in an acute care environment. Though less likely than edema to be directly attributed to changes in cell permeability and microcirculation.
Amount of compression for garment to prevent hypertrophy and facilitate scare remodeling after significant burns?
- Deep partial-thickness or full-thickness (burns typically taking greater than 14 days to heal)
- 15-35mmHg to create an environment that facilitates the balance of collagen synthesis and lysis
- worn for 22-23 hr/day for 2weeks and 2 months after wound closure or grafting. May continue up to 2 years.
- Replace the garment every 3-6 months
*
Epidermis Layers
Superficial to deep
“Come Lets Get Sun Burned”
Corneum
Lucideum
Granulosum
Spinosum
Basal
Edema severity scale
1+: pitting edema ~2mm in depth and disappears in under 10 seconds.
2 +: 4mm in depth and disappears in 10 – 15 seconds.
3+:pitting edema ~ 6mm in depth that lasts from 16 seconds to potentially longer than one minute.
4+: 8mm in depth and can last anywhere from 2-5 minutes.
What to put on a facial burn?
Bactrin
mild antimicrobial activity, is nontoxic, moisturizing, and can be reapplied one to five times daily, so it is useful for facial and perineal burns.
Grade 3 Wagner diabetic foot ulcer has scant exudate. What is the best dressing for this?
Antimicrobial dressing.
Commonly used with neuropathic foot ulcer.
