Integumentary System Flashcards
What is the primary function of the epidermis?
Maintain skin integrity as a physical barrier against:
- bacteria
- shear
- friction
- irritants
- protect aginst loss of fluid at cellular level
What is the primary function of the dermis?
Provide tensile strength and support
retain:
- moisture
- blood
- O2 to the skin
Skin receives how much of the blood volume?
1/3 of the bodies
Normal wound healing
Phase 1
Inflammatory phase
1-10 days
If interrupted = chronic inflammation can happen
Normal wound healing
Phase 2
Proliferative phase
3-21 days
Interruptions or delay = chronic wound
Normal wound healing
Phase 3
Maturation phase
7-2 years
Scar tissue will remodel but strength is 80% of normal tissue
What influences wound healing?
- age
- comorbidities
- edema
- inappropriate wound care
- infection
- lifestyle
- stress
- medications
What is healthy skin reliant on?
The proper function of the peripheral vascular sysem and lymphatic system
What is necessary for wound healing?
Oxygen because otherwise infection risk is increased
Perfusion to wound can be compromised by?
- arterial insufficiency
- presence of edema
- necrotic tissue
What is the environment needed for wound healing?
Important to set up a moist wound environment
- proper wound hydration is the most important EXTERNAL factors
What are the basic principles to set up an optimal environment?
- barrier to cover the wound that is “breathable”
- preserve fluid in the wound bed
- maintain the peri-wound integrity by controlling heavy exudate
- changing bandage when leakage happens outside of borders
What should we include when documenting wounds?
- location
- size
- shape
- edges
- tunneling, undermining, sinus tracts
- peri-wound area
- pain
Drainage type
Serous type
Color, thickness, healing phase
Color
- clear, light color
thickness
- think, watery
healing phase
- inflammatory and proliferative phase
Draining types
Sanguineous
Color, thickness, healing phase
Color
- red color
thickness
- thin and watery
Healing phase
- inflammatory and proliferative phase
Draining types
Serosanguineous
Color, thickness, healing phase
Color
- clear or tinge light of red or pink
Thickness
- thin and watery
Healing phase
- inflammatory and proliferative phase
Drainage type
Seropurulent
Color, thickness, healing phase
Color
- cloudy, opaque, yellow or tan
thickness
- thin and watery
Healing phase
- early warning signs of infection (abnormal findings)
Drainage types
Purulent
Color, thickness, healing phase
Color
- yellow and green
thickness
- thin and viscous
Healing phase:
- wound infection (abnormal findings)
Necrotic tissue types
What is slough?
Moist, stringy or mucinous white/yellow tissue that is attached to the wound bed
- easily removed
Necrotic tissue types
What is eschar?
Hard, leathery, black/brown, dehyrated tissue and is usually adhered to healthy ones under
Necrotic tissue types
What is gangrene?
Death and decay of the tissue because interrupted blood flow
Necrotic tissue types
What is hyperkeratosis?
“callus” is white/gray
- texture firm to soggy depending on moisture surrounding it
Wound closure
What is the primary intention?
Surgeon closes the wound edges by approximating while using sutures, staples, graphs and glue
- if infection or maceration causes it to open = “dehiscence”
Wound closure
What is secondary intention?
When a wound is left to heal on its own
- new tissue is laying down in the wound bed which closes the area until it is healed from the deepest layers to most superficial
Wound closure
What is tertiary intention?
“delayed primary” meaning the secondary intention fails then has to be surgically closed
- when delay is purposeful = infection
- once healed = closure happens
What is the clinical sign that a wound is not following a normal pattern?
- change in color and ordor
- persistent edema
- necrotic tissue formation
- tunneling or undermining
- infection
- wound edge builds up a ridge that curls under itself
- hypertrophic scarring or keloid
What are the clinical features of a venous ulcer?
Pulses - Pain - Color - Temp - Edema - Skin changes - Ulceration - Gangrene
Color
- normal
Pain
- none to aching (dependent to position)
Color
- normal or cyanotic (may see dark pigmentation)
Temp
- normal
Edema
- often marked
skin changes:
- pigmentation
- statis dermatitis
- skin gets thick as scarring develops
ulceration
- may develop medially
- wet with large amount of exudate
gangrene
- absent
What are the clinical features of aterial ulcers?
Pulses - Pain - Color - Temp - Edema - Skin changes - Ulceration - Gangrene
Pulses
- poor or absent
pain
- often severe
- intermittent claudication
- progressing to pain at rest
color
- pale on elevation
- dusky rubor on dependency
temp
- cool
edema
- usually absent
skin changes
- trophic changes
- loss of hair on foot and toes
- nails thicken
ulceration
- on toes or feet
- can be deep
gangrene
- black gangrenous skin adjacent to ulcer can develop
What are the clinical features of diabetic ulcers?
Pulses - Pain - Ulceration - Gangrene
Pulses
- may be present or diminished
pain
- typically not painful
- sensory loss usually present
ulceration
- may develop due to trauma to insensitive skin
gangrene
- may develop if left untreated
What are the clinical features of pressure ulcers?
Pain - Color - Temp - Skin changes - Ulceration - Gangrene
pain
- can be painful if sensation is intact
color
- red
- brown/black
- yellow
temp
- may be warm if localized infection is present
skin changes
- inflammatory response with necrotic tissue
ulceration
- typically occurs over bony prominences
gangrene
- may develop if left untreated
What are the characterisitics accounted for the Braden Scale?
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
Staging pressure ulcers
Stage 1
intact skin with non-blanchable redness over a localized area over a bony prominence
dark pigmented skin may not be seen
its color may differ according to the area
can be painful, firm, soft, warmer or color than adjacent skin
warning signs for at-risk patients
Staging pressure ulcers
Stage 2
partial thickness loss of dermis that shows as a shallow open ulcer with a red-pink wound bed with sloough
can be present as in intact or open/ruptured serum-filled blister
Staging pressure ulcers
Stage 3
full thickness tissue loss
subcutaneous fat may be visible but the fascia and structures beneat the fascia are not exposed
slough may be present but does not obscure the depth of tissue loss
can include undermining and tunneling
Staging pressure ulcers
Stage 4
Full thickness tissue loss with exposed bone, tendon or muscle
slough or eschar may be present on some parts of the wound bed
often includes undermining and tunneling
Staging pressure ulcers
Suspected deep tissue injury
purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
area may be preceded by tissue that is painful, firm, mushy, bogggy, warmer or coolr as compared to adjacent tissue
Staging pressure ulcers
Unstageable
Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed
What are the risk factors of diabetic foot ulcers?
foot tissues
- poor footwear
- foot deformities
- trauma to the foot
noncompliance with disease management
lack of protective sensation
skin changes
- dry, red, shiny skin, previous ulcers
history of:
- amputation
- alcohol/tobacco use
- immobile
- increased age
- weak immune system
- vascular disease
Wagner Diabetic Ulcer Grade Classification
Stage 0
no open lesion
may have pre-ulcerative lesions (healed ulcers or presence of bony deformity)
Wagner Diabetic Ulcer Grade Classification
Stage 1
Superficial ulcer
- does not involve any subcutaneous tissue
Wagner Diabetic Ulcer Grade Classification
Stage 2
deep ulcer
- penetrating through subcutaneous tissue
- has potential to expose bone, tendon, ligament, joint capsule
Wagner Diabetic Ulcer Grade Classification
Stage 3
Deep ulcer
- with osteitis, abscess or osteomytelitis
Wagner Diabetic Ulcer Grade Classification
Stage 4
Gangrene
- likely requiring amputation
Wagner Diabetic Ulcer Grade Classification
Stage 5
Gangrene
- suspected deep tissue injury
- requiring amputation
