Integumentary system Flashcards
What is the rule of 9s?
This refers to the method to determine % of body suffering burns: Head and neck- 9% Ant trunk - 18% Post trunk - 18% both anterior UE - 9% both post UE - 9% Genitals 1% Both ant LE 18% Both post LE 18%
How does the rule of 9s change for age 1-10 year old
Take 9% off the lower extremities and add to the head and neck - add 1% back each year until 9 years old.
What is the Wagner Ulcer classification scale?
0- no open lesion, healed ulcer
1 - Superficial ulcer
2. Deep ulcer including subcutanous tissue, may expose bone, tendon, mm
3. Deep ulcer with OM
4. Gangrene of digit
5. Gangrene of foot requiring disarticulation
What are the stages for pressure ulcers
I - intact skin, bony prominence, non-blanchable, pain/itch
II - Partial thickness tissue loss, shallow open ulcer, red wound bed, blister
III- Full thickness tissue loss into subcutanous layer - tunneling
IV - Full thickness exposed tendon, muscle or bone, eschar, undermining, tunneling,
Unstagable - full thickness tissue loss covered with eschar - needs debriding to stage.
What are the types of exudate?
Serous - clear, light, thin, normal
Sanguineous - red colour, thing, watery, blood, may be brown if dried - normal (moderate amount or greater indicates tissue damage)
Serosanguinous: light red or pink, thin and watery, normal in healthy healing tissue
Seropurulent - cloudy or opaque with yellow or tan colour, thin and watery, Early sign of infection
Purulent - yellow or green colour, thick, viscous indicates infection
What are the types of odour associated with wounds? What are they caused by
Pseudomonas infection - sweet odour, thin, foamy green drainage
Clostridium - strong pungent odor associated with tissue necrosis
Putrescine -pungent can cause vomiting, rotten smell
Caused by tissue degredation, necrosis or anaerobic bacteria
What are the 9 things that are examined when treating a wound
- Examine for tunnelling
- report colour and tissue involved record presence of granulation or epithelialization
- Temperature
- Girth (can use volumetric measures for girth but not for wound volume
- Viability of periwound tissue - halo, warmth, swelling
- Sensory integrity
- signs of infection
- wound scar tissue - banding, pliability, texture
- photographic records - wound appearance.
What are the 4 types of burn
Thermal - from conduction or convection
Electrical - Complications include arrthythia, resp arrest, renal failure, neuro damage
Chemical - Reactions conitnue until chemical is diluted
Radiation - altered DNA complications include blistering, desquamation, non-healing wounds, tissue fibrosis, discoloration, new malignancies
What are the three classifications of burn zones
Zone of coagulation - irreversibly injured, cell death
Zone of stasis - cells injured, may die without specialised treatment
Zone of hyperemia - minimal cell injury, should recover
What are the signs of a 1st degree burn and what is the rate of healing - superficial burn
Redenss that lasts >20 minutes, no blistering, epidermis only, 3-7 days
What are the signs of a 2nd degree burn and what is the rate of healing - Superficial partial thickness burn
Blisters, separation between dermis and epidermis. Pain with more fluid loss. Local circulation disrupted. 7-21 days
What are the signs of a 2nd degree burn and what is the rate of healing - Deep partial thickness burn
Red or white appearance, blistering, severe pain, severe damage to dermis and epidermis. Injury to nerve endings hair follicles, sweat glands. 21-28 days
What are the signs of a 3rd degree burn- Full thickness burn
Through dermis and depidermis, may involve subcutanous tissue. Damage to muscle and tendons causing risk for developing contracture. Gray, white or black appearance, eschar.
What are the two types of scarring associated with a full thickness burn?
Hypertrophic scar - raised scar that stays within the boundaries of burn wound
Keloid scar - raised scar that extends beyond boundaries of original burn wound
What is a 4th degree burn
Electrical burns - large thermal burn where current exits the body and a smaller injury at the entrance point. Extensive tissue damage.- destruction of vascular system.
What are the characteristics of an arterial insufficiency ulcer?
- lower third leg, toes, web spaces, lat malleolus
- Smooth edges, well defined, deep
- Minimal exudate
- painful
- diminished or absent pedal pulses
- Normal or no edema
- Decreased skin temperature
- thin, shiny skin, hair loss, yellow nails
- Leg elevation increases pain
Rx: protect limb, inspect daily, avoid leg elevation, appropriate shoes with seamless socks
What are the characteristics of a venous insufficiency ulcer?
- Proximal to medial malleolus
- irregular shape, shallow
- mod to heavy exudate
- mild to mod pain
- normal pulses
- increased edema
- normal skin temp
- flaking, dry skin brownish colour
- leg elevation decreases pain
- limb protection, risk reduction, compression, elevation of legs, AROM ex, shoes and socks appropriate
What are the characteristics of a neuropathic ulcer?
Areas exposed to pressure or shear during WB
- Well defined, oval or circle, little necrosis, good granulation
- low to mod exudate
- no pain
- diminished or absent pulses
- normal edema
- decreased skin temp
- dry, inelastic, shiny skin, decreased or absent sweat and oil
- loss of protective sensation
Rx: repositioning 2 hourly in bed, manage excess moisture, inspect skin daily
What are the characteristics of a pressure ulcer?
- areas of prolonged pressure - bony prom
- Initially bruising or purple blisters
- no exudate
- mild pain
- normal pulses
- no edema
- increased skintemp
- shearing forces, moisture, temperature, friction, malnutrition
- Reposition every two hours
What are the 6 types of wound?
Abrasion - shear and friction forces
Avulsion - aka degloving - skin detatched from underlying structures
Laceration - trauma - shear, tension, high force compression
Penetrating - entering the interior of organ or cavity
Puncture - penetrates skin and underlying tissue
Skin tear - trauma to fragile skin
What is dermatitis
Inflammation of skin diagnosed as:
Acute; red oozing, crusting, rash, exudate
Subacute: erythematous skin, scaling, scattered plaque
Chronic: thickened skin, skin marking from scratching, post inflamm pigmentation changes.
Impetigo is..
A bacterial skin infection caused by staph/strep infection Associated with inflammation, small pusfilled vesicles, itchy, contagious. Rx: AB
Cellulitis is…
Bacterial skin infection - strep or staph, poorly defined and widespread. Hot, red edematous. can be contagious. AB elevation, cool wet dressing.
Abscess is
Commonly from a staph infection. Cavity containing pus, surrounded by inflamed tissue, result of localised infection. Will naturally burst out of the skin if left alone. Rx: drain.
Fungal infections include
Ring worm and athletes foot.
Parasitic infections include
Scabies and lice
Immune disorders: Psoriasis
Chronic autoimmune disease of the skin, red plaques covered with silvery scale.
Rx; corticosteroids, oinments, immunosuppressive drugs
Lupus erythematosus
Autoimmune disease - chronic progressive inflammatory of connective tissue.
Red rah with raised scaly plaques, butterfly rash of face, joint pain.
Scleroderma
Chronic autoimmune diffuse disease of connective tissue. - Fibrosis of skin, joints, blood vessels and internal organs. Skin taut, firm, edematous, firmly bound to subcutaneous tissues. No cure but can treat symtoms
Polymyositis (PM)
Connective tissue disease - immune. Symmetrical distribution. Edema, inflammation, degeneration of muscles. Primarily proximal mm. Pelvic girdle, neck, pharynx. Some forms have dermatitis.
Types of benign tumors include
Seborrheic keratosis, actinic keratosis, Benign nevus (common mole)
Types of malignant tumors include:
Basal cell carcinoma, Squamous cell carcinoma, malignant melanoma.
Skin graft types include
Allograft - other human skin
Xenograft - other species (temporary)
Biosynthetic - collagen and synthetics
Cultured skin - lab grown from patients own skin
Autograft - use of patients own skin
Split thickness graft - epidermis and upper layers of dermis from donor site
Full thickness graft - epidermis and dermis from donor site
z-plasty - surgical resection of scar contracture used to lengthen burn scar
Hydrocolloids
Gel forming polymers - backed by strong film or foam adhesive.
Ind: Partial and full thickness granular or necrotic tissue
mild exudate
Adv: enables autolytic debride, no secondary dressing, protects from microbes
Disadv: may traumatise surrounding skin
- not for infected wounds
Hyrdogel
Gel forming materials and water - protect wounds
Ind: superficial and partial thickness wounds
Minimal exudate
Requires secondary dressing. Not for heavily draining wounds
Transparent film
Transparent polyurethan - permeable to oxygen, impermeable to water/bacteria
Ind: Superficial and partial thickness
Min drainage
Not for infected wounds.
not for excessive exudate
Foam
Hydrophilic base that contacts the wound and hydrophobic outer layer.
Partial and full thickness wounds. Secondary over hydrogel. Varying levels of exydate
Can be adhesive or non adhessive. Moderate absorption.
Gauze
Patch for protection. Infected or non-infected.
Sticks to the wound bed - lots of dressing changes, high infection rate.
Alginates
Seaweed extract, calcium ions that combine with wound exudate to create gel
Full/partial thickness wounds, draining/infected wounds
Cannot be used on wounds with exposed bone or tendon. Requires secondary dressing.
highly absorptive
Silver sulfadiazine
Can be applied with or without dressings. Painless.
Burn care
Does not penetrate eschar
Sulfamylon
infection control in full thickness ulcers/burns
Pain at site of application
Silver nitrate
non-allergenic, painless
used for burn care
Removal is painful, discolours, poor penetration
Panafil
Debrides dead tissue/things pus from superficial layers -improves recovery time/odor
Used for wounds and burns.
Povidone-iodine
Antifungal - easily removed with water
Burn care
Gentamicin
may be covered or left open.
Burn care
Dakin
Antiseptic
Infected wounds/bacteria
Santyl
Enzymatic debriding ointment - removes dead skin from wounds and burns
Most occlusive to non occlusive dressings in order
- Hydrocolloids
- hydrogels
- semipermeable foam
- semipermeable film
- impregnated gauze
- Alginates
- traditional gauze
Most Moisture retentive to least moisture retentive
- Alginates
- semipermeable foams
- hydrocolloids
- hydrogels
- semipermeable films
What dressings to use based on the amount of exudate: Dry wound: Minimal exudate: Moderate exudate: Heavy exudate:
Dry wound: hydrocolloid
Minimal exudate: hydrocolloid, hydrogel, silicone, transparent film
Moderate exudate: Foam, calcium alginate, negative pressure hydrocolloid
Heavy exudate: calcium alginate, foams, absorbant dressing, negative pressure therapy
Types of selective/non-mechanical debridement include
Sharp, Autolytic, Enzymatic
types of non-selective/mechanical debridement include
Wet to dry, hydrotherapy, irrigation
Face and Hand burns are classified as what severity?
Considered major burns
What is a Kaposi sarcoma
Cancer in skin, lymph, organs - red/purple/brown/black lesions
