Midterm Flashcards
The skin is divided into what two layers?
-The dermis and epidermis
What is just deep to the dermis and allows it to move freely over internal organs?
-The hypodermiS
What are the layers of the epidermis from deep to superficial?
-Basale, Spinosum, Granulosum, lucidum, corneum
What layer of the epidermis houses active keratinocytes?
-The Stratum Basale
Which layer of the epidermis helps the skin withstand friction and shear force?
-Stratum Spinosum
What layer of the epidermis helps the skin prevent water loss?
-The stratum Granulosum
What is contained in the stratum granulosum that prevents water loss?
-Intercellular space comprised of lipid rich material
What layer of the epidermis provides protection from the environment?
-Stratum lucidum
In what areas of the body in the stratum lucidum visible?
-The palms and bottoms of feet
What layer of the epidermis do keratinocytes become corneocytes?
-The stratum Conreum
What layer of the epidermis forms an acid mantle to make the skin more resistant to infection?
-The stratum corneum
Where are melanocytes located?
-Between the straum basale and the stratum spinosum
What type of cells are located in the stratum spinosum and provide an immune response?
-Langerhan cells
What type of cells are located in the stratum basale and detect light touch and tactile sensation?
-Merkel cells
Where does blood flow run in the dermis?
-Just deep to the basement membrane, to be able to supply the epidermis; allowing nutrition to the active keratinocytes
What are the name of the shunts of blood flow that run through the dermis?
-ateriovenous anastmoses
what does the dermis contain to help carry out excess fluid?
-lymphocytes
Where do nerve running through the dermis become free nerve endings?
-Just before the epidermal junction
What is the more superficial layer of the dermis?
-The papillary dermis
What do fibroblasts in the papillary dermis create?
-Elastin and type I collagen
The collagen and elastin made in the papillary dermis are responsible for giving what characteristics to skin?
-Turgor and toughness
What do the firbroblasts in the papillary dermis create that helps aid wound closure?
-Hyaluronic acid
What is the deep layer of the dermis that is located over the subcutaneous fat?
-The reticular Dermis
What is found in the reticular dermis that detects light touch and vibration
-Meisner’s Corspuscle
What is the term for skin loss only on the epidermis?
-Erosion
What type of wounds are erosion wounds?
-1st degree burns and pressure sores
Partial thickness wounds involved what layers?
-The epidermis and papillary dermis (demonstrate bleeding)
What type of wounds are partial thickness wounds?
-2nd degree burns and pressure sores
What wounds involve the dermis, epidermis and hypodermis?
-Full thickness wounds
What is the first phase of skin healing?
-Hemostasis
How long does hemostasis last?
-less than 1 hour
What is hemostasis directed by?
-platelet aggregation
What occurs during hemostasis?
-The wound stops bleeding and scab begins to form
Clinical signs of hemostasis are similar to the inflammation stage, but what is the factor that distinguishes between the two?
-clot formatoin
What is the inflammation stage of wound healing also known as?
-scavenger or neogenesis
What does the inflammation stage of wound care mainly invole?
-cleaning the wound
What begins immediately after the injury to get rid of necrotic tissue?
-autolytic dedridement
What does the proliferation stage of wound healing entail?
-injured tissue being replaced by healthy cells undergoing mitosis
What is needed to provide nutrients to the wound and remove waste and deris?
-Angiogenesis
What is granulation tisse characterized by?
-Beefy Red appearance
What is the final stage of wound healing that begins after wound closure?
-Maturation/remodeling phase
What occurs in the maturation stage?
-A aggregation of cells that increases the strength of the wound
When a wound heals, how much strength does it retain from the original skin?
-80%
What is the term for the recurrence of wounds in the same area due to the decreased in tensile strength?
-Recidivism
What are the 3 classifications of wound response?
- Healing by primary intenetion
- Healing by delayed primary intention
- Healing by secondary intention
What type of healing will you typically see after surgury?
-primary intention (miminal scaring)
What is the example of a wound healing by primary intention?
-Those that have been surgically closed and are free from bacteria or pathogens
Wounds the heal by primary intention typically heal by when?
-2 weeks
What are wounds healing by delayed primary intention characterized by?
-wounds that have some sort of problem on the inside that prevent the edges from approximating; can be debris
What can result due to a delayed primary intention wound?
-A granuloma
How do delayed primary intention wounds normally resolve?
-Surgically
What is the usual wound healing process for non-surgical wounds?
-Secondary intention (progress through all wound stages)
Wounds seen in the clinic will be what two types of wounds?
-Delayed primary intention or sedondary
Cells communicate in the matrix to provide a better environment for what?
-wound healing
What breaks up the wound matrix to enhance the surrounding wound bed allowing for epithelial migration?
-Plasminogen activators and Mixed metalloproteinases (MMPs)
The majority of the drainage that leaves wounds consists of what?
-Proteins
What is the ECM of the skin comprised of?
-Collagen, elastin, proteoglycans and GAGs
What type of wounds occur with inadequate healing and may take months or years to close?
-Chronic wounds
What do chronic wounds typically occur because of?
- Foreign debris
- bacterial disruptions
- disease processes (circulatory disorders)
What are the most common chronic wounds?
-Venous insufficiency wounds
What 7 factors can impead healing?
-Infection, medications, comobities, cancer/radiation, autoimmune disorders, stress, lack of sleep
What can be applied to wounds that are being delayed by infection?
-antimicrobials
Fungal infections most commonly occur where?
-in moist environments under dressings
How can corticosteroids delay wound healing?
- allows for a lag time for inflammatory cells and fibroblasts to occupy the area
What can be given to those with prolonged steroid use the allow for better wound healing?
-ZMAC (zinc, magnesium, Vitamin A, Vitamin C)
What effects to NSAIDs have on wound healing?
-Decrease platelet aggregation, decrease tensile strength, and decrease granulation formation during the proliferation stage
How does diabetes delay wound healing?
-it increase glucose levels and impairs leukocyte function
How does arterial insufficiency delay wound healing?
-limits the ability to remove waste and provide nutrients
What is a large indicator of wound healing?
-cardiac function
What type of cells are particularly effected by ionizing radiation therapy and causes decreased tensile strength of the tissue and delayed healing?
-Fibroblasts
Why does chemotherapy cause poor wound healing?
-it kills good wound healing cells as well as cancer cells
What cancer treatment can cause decrease blood flow and sensation to the extremites and may lead to further tissue degeneration?
-CIPN
What cancer treatment may cause nutrional deficits and cause poor healing?
-Chemoside
Stress causes the release of what that will impair the response to injury?
-epi and norepi
How does smoking impair healing?
-it causes vasoconstriction and decreases the healing response
What can lead to insulin resistance and high glucose levels that can inhibit healing in all phases?
-alcohol consumption
What is the normal what blood cell count?
-4.5-11
What may lead to increased WBC count?
-infection or trauma
What does a low WBC count mean?
-decrease immune response to bacteria
What is the normal levels of hemoglobin?
-12-18 g/dL
Increased of decrease levels of hemoglobin will cause what?
-The inability of the wound to progress
What is the normal level of hematocrit?
-36-50%
What is increased hematocrit a sign of?
-thrombi/emboli
What is normal prothrombin time?
-2.5 seconds
What does increased prothrombin time cause?
-easy bleeding
What does decrease prothrombin time cuase?
-increased clotting
What is the normal HbA1C range?
-less than or equal to 5.7 percent
increase HbA1C will cause what?
-Delayed wound healing
What is the average glucose levels?
-less than 100 mg/dL
What dictates the type of wound healing?
-Tissue loss
What is the name for the Red Yellow and Black Classification system?
-Marion Lab Scale
What is the Marion Lab scale used to describe?
-the wound surface that correlates with the specific therapy needs
What are Red wounds described to be?
-Healthy, cleaning, healing and granulating
What is a yellow wound indicative of?
-A possible infection, or presense of necrotic tissue
What are black wounds characterized as?
-Necrotic or dead
What is the most widely known wound classification system used for pressure ulcers?
-National Pressure Ulcer Advisory Panel Pressure Ulcer Staging System
What does the NPUAP used to describe?
-The severity of the wound in order to dictate treatment protocols for reimbursement with regard to treatment products
What is the wagner scale used to classify?
-ulcers
What was the wagner scale originally used to diagnose and treat?
-the dysvascular foot
How does the wagnar scale describe a wound?
-The depth of the injury and presence of infection on a 0-6 scale
What is a grade 0 ulcer on the wagner scale?
-A pre or postulcerative site
How is a grade 1 ulcer on the wagner scale described?
-Superficial wounds through the epidermis or also the dermis, but no subcutaneous involvement
How is a grade 2 ulcer on the wagner scale desribed?
-penetrates through then tendon and capsule but the done and joint is not effected; full thickness wound
What is a grade 3 ulcer on the wagner scale?
-ulcer that affects joint and bone with abscess or osteomyelitis
What is a grade 4 on the wagner scale?
-forefoot gangrene within a digit
What is a grade 5 on the wagnar scale?
-Whole foot gangrene, requires amputation proximal to the digit
What is the University Texas system used to classify?
-Diabetic foot ulcers when a diabetic nephropathy is present
What 4 things does the UT scale grade?
-(A) wound depth; (B) infection, (C) Ischemia, (D) infection
What is step 1 in the wound care process?
-General assessment (regular PT exam)
What is step 2 in the wound care process?
-Diagnosis
What is step 3 of the wound care process?
-Prognosis and goal
What is step 4 of the wound care process?
-Re-evaluation
What things are important to ask the patient regarding a wound?
-onset, appearance, signs and symptoms, medication, and psycho-social history
What is part A of the diagnosis proccess of wound assessment?
-an in depth examination of testing for related factors and co-morbities, and focused wound examination
What is part B of the diagnosis of wound assessment?
-Forming the diagnosis from the info gathered in part A
What should to do before asessing a wound?
-Clean it to give a clear picture
What is the most commonly used method to document wound deminsions?
-The clock method
How is the perpendicular method of wound deminsions performed?
-Take the longest measure then measure perpindicular to that
What is considered the 12 position with the clock method?
-The head
Where is the width of the wound measured with the clock method?
-Perpindicular to the length, usualy at its maximum width
What is the disruption in the attachment of the skin to underlying structures?
-Undermining
What is undermining typically noticed as?
-dark, discolored tissues surrounding the periwound
What should you use to note the location of undermining?
-Clock position
Where can tunneling occur?
-Between two wound, or within the same wound
Where can tunneling not occur?
-it cannot span under around the wound
What type of non-viable tissue is describes are nercrotic and brown and black color?
-Ecshar
How does eschar often appear?
-Flat and shiny, with a hard and dry texture
What type of tissue is described as non-viable subcutaneous tissue that is the result of autolytic debridement?
-Slough
What is the appearance of slough?
-Soft and yellow
What stage of wound healing is granulation tissue seen?
-Proliferation
How does viable muscle tissue in a wound present?
-striated and red and is painful to tactile sensation
How does non-viable muscle in a wound present?
-greyish, cannot contract and is not painful
What need to be kept moist at all times to prevent infection if is exposed in a wound?
-periosteum
What must you do to rule out osteomyelitis?
-Perform a biopsy
What type of wounds are tendons seen in?
-full thickness wounds
How does viable tendon appear in a wond?
-shiny due to the paratendon sheath
Why must exposed tendons in a wound be kept moist?
-to maintain the viability
What type of viable tissue is described as shiny globules with a dull yellow appearance?
-Adipose
Why is the window viability of adipose typically short?
-It has poor blood supply
What type of tissue is described as granulation tissue that overides the surface
-Hypergranulation
What is hypergranulation a sign of?
-abnormal healing
What will hypergranulation prevent?
-Wound edges from approximating
What may be used to caogulate tissue and promt proper healing?
-Silver nitrate
What has been shown to decrease the incidence of hypergranulation?
-Foam dressings with pressure, or topical corticoids
Why is proper documentation of drainage neccesary?
-to recognize the phase of healing and allow for a clear picture of healing status
What is a scant amount of drainage?
-A small amount of drainage on dressing after removal
What is minimal drainage?
-25% of the dressing is covered
What is moderate dressing?
-50% of the dressing is covered
What is heavy drainage?
-100% of the dressing is covered
What is copious drainage?
-Multiple layers of the dressing are covered
What is strike through drainage?
-Visible through the last layer of dressing
What type of drainage is described a clear serum?
-Serous
What type of drainage is described as bloody?
-sanguinous
What type of drainage is described as bloody and clear?
-Serosanguinous
what type of drainage is is described as a viscous puss?
-Purulent
What is characteristic of drainage is indicative of infection?
-Bad odor
If the periwound is red what would that be described?
-Erythema
If the periwound is pale, what what would that be described as?
-Ischemic
The brown/purple stain that is typical with venous insufficiency is known as what?
-Hemosiderin
When should wound odor be assessed?
-After cleaning
What type of infects has characteristically sweet odor like corn tortillas?
-Psueomonas
Malignancy has what type of odors?
-varying
What type of infection has a foul odor?
-Wet Gangrene
Where does the arterial system begin?
-The ascending aorta
What are the symptoms of Claudications?
-heavy legs with cramping in the calf that increases with exertion
When will individual with PAD have pain during rest?
-when laying horizontally or when they are propped up
What are 7 risk factors for arterial wounds?
-Artherosclerosis, Smoking, Obesity, Diabetes Mellitus, Hypertension, Hypercholesteremia, Family History, Nutrtition
What test uses a doppler and BP cuff to calculate the systolic pressures and compare to normal values?
-ABI
What is an expansion of the ABI and require pressures taken at various points along the limb to better localize the ischemia?
-Segmental plethysmography
What combines ABI and SP and uses ultrasound to show details of the specific vessels that may be occluded?
-Arterial duplex loans
What test allows for the measurement of oxygen delivery to the site to be measured and has been show to help determine the amount of ischemia in the limb?
-Transcutaneous oxygen measures
What does Magnetic Resonance Radiography Angiography help visualize?
-The vessels and ischemia
What is the Ankle Brachial Index?
-the ratio of brachial Systolic BP to Ankle Systolic BP
When you obtain the BPs on the LEs, what side should you use?
-The one with the highest value, or one with a wound on it
What UE value should you use?
-The highest
An ABI >1.3 means what?
-False Elevation; heavy vessel calcification
What is normal ABI?
-1.0-1.29
What is considered borderline ABI?
-.091-1.0
What ABI value indicated mild PAD?
-.7-.9
What ABI values indicates moderate PAD?
-0.4-0.69
What ABI value is considered severe PAD?
-<0.4
What is the rubor of dependency test?
-Screens for artery insufficiency or ischemia
How do you perform the Rubor Dependency Test?
-Start with patient in supine, then elevate legs to 30 Degrees; wait for palor to be observed; then drape legs off the edge of table
What are normal results For the Rubor Dependency test?
-When you drape leg off table, it should return to a pinkish color
What are abnormal results for the rubor test?
-The foot will appear bright red
What causes the abnormal response in rubor test?
-Rapid dilation of the arteries to try to reprofuse the extremity quickly
How do arterial insufficiency wounds present?
-Small round and regular borders- like a punch hole
How does the wound bed appear with a vascular insufficiency wound?
-usually is pale due to imapired blood flow (dont heal)
Where do vascular insufficiency wounds normally occur first?
-on the digits
When do vascular insufficiency wounds become painful?
-when blood flow is gravity assisted
What might occur if a vascular insufficiency wound exposes bone?
-osteolyelitis
What is vital in treating arterial insufficiency wounds?
-Protection and ensuring blood flow
What type of therapy has been shown to increase blood flow and and help heal arterial insufficiency wounds?
-infrared lights
If an arterial insufficiency wound is stable with eschar and does not appear to have infection what should you not do?
-debride it
How does a stable wound present?
-hard to touch, no drainage and no redness
How do veins differ from arteries?
-they do not contain as much smooth muscle or elstin; allows them to withstand greater volumes of fluid
What occurs if there is a pathology in the venous system?
-Edema
What results from leaky valves?
-Variscosities
How do hemosiderin stains develope?
-Leaky valves leak blood into interstitial spaces and die, once they die the release hemoglobin into the fluid and turns a dark brown
Venous insufficiency normally causes edema where?
-in the lower leg
Edema expanding outside of the lower leg is normally caused by what?
-lymphadema
What position is normally used to assess increased venous distention?
-Standing
What test measures refill time by performing ankle pumps using a diode?
-photothysmography
What invansive procedure calls for a needle to be stuck into the pedal vein and measures pressure at rest and after exercise?
-Ambulatory venous pressure
Where do venous insufficiency normally occur?
- in the gaiter area of the medial lower leg
How do venous insufficiency wounds normally occur?
-insidously and are preceded by initial skin changes
How do venous insufficiency wounds normally present?
-shallow with little to no eschar formation
How will the periwound look like with a venous insufficiency wound?
-thickened skin or varicosities and hemosiderin staining
What will be present in a venous insufficiency wound if there is not arterial insufficiency?
-Drainage
What is the gold standard for treating venous insufficiency wounds?
-Compression
What type of patient should you not use compression on?
-CHF
For ambulatory patients with a venous insufficiency wound, what type of wrapping should you use?
-Figure 8 (provides twice as much compression)
What was an issue with the unna boot to treat venous insufficiency wounds?
-it does not change size onces edema goes down
What is the preferred compression technique for venous insufficiency wounds?
-4 layer compression
What is the 1st layer of the 4 layer compression?
-soft rolling of padding to build up the LE to assure a conical shape
What is the 2nd layer of the 4 layer compression?
-A non-eleastic layer providing the first layer of compression
What layer of the 4 layer compression provides the figure 8 pattern?
-The 3rd
What is the 4th layer of the 4 layer compression?
-adheres the wrapping together
How often must a 4 layer compression dressing be changed?
-3-7 days
What is the removal of dead, damaged or devitalized tissue from a wound bed?
-Debridement
What is the foundation behind debridement?
-to encourage wound healing in order to prevent infection, reduce chronic inflammation process when necrotic tissue is in the wound bed and promote growth in order to jumpstart the wound healing process in the acute stage
When should you debride a wound?
-to remove necrotic tissue if it is warranted, the perform maintenance throughout the healing process
What does necrotic tissue look like?
-brown/black eschar or yellow slough
What should the INR be at to perform debridement?
-2.5 (higher would cause more bleeding)
What is a precaution to debridement?
-blood thinners
What is a good indicator or wound prognosis?
-Pain
What should you always perform before debridement?
-if the ABI is low, you must refer
Those with ABIs less than what is contraindicated for debridement?
-.4
What type of wounds will need a vascular consult prior to debridement?
-Dry gangrene or dry ischemic wounds
What needs to be treated before debridement can occur?
-infection (fever)
What bacterial skin infection is characterized by severely inflamed, painful limbs, with heavy odor and drainage?
-Cellulitis (must treat with antibiotics before debridement)
What must you do if there is is exposed bone, tendon or any prosthetic device?
-Refer out to determine viability of the structure
Should you debride a wound with stable eschar and no signs of infection?
-NO
Where is stable eschar likely to present?
-on the heel
What type of debridement uses the bodies natural healing mechanism to debride non-viable tissue?
-Autolytic
How must the wound be prepared for autolytic debridement?
-need to be cleaned, and kept at the proper moisture
What can you do to eschar to promote healing from the inside out?
-Cross hatch it
What are some advantages for autolytic debridement?
-It is selective, improves rapidly and can be combined with other debridement types
What disadvatages come with autolytic debridement?
-may have to educated caregiver repeatedly, slower than sharp, and increased risk of infection
What type of debridement uses a collagenase to selectively break up non-viable tissue?
-Enzymatic
What is the common enzyme used to perform debridement?
-Santyl
What must you perform before enzymatic debridement?
-Clean it with a neutral pH cleaner
What type of debridement refers to some outside scource for debridement?
-mechanical
What type of dressings can be place on a wound, for non0viable tissue to attach to, to then be removed?
-wet to dry dressings
Why should you moisten the wet to dry dressing before remove?
-To limit the amount of granulation tissue that is taken with the dressing
What type of debridement uses pulses of water to gently clean the wound or debride it?
-Pulse Lavage
What range of PSI should be used for Pulse Lavage?
- 4-9 PSI
What PSI should you avoid to prevent tissue injury?
-15
What is the mos rapid form of debridement?
-Sharp
What are the disadvantages to sharp debridement?
-Pain, increased potentiol for complications
What should you checl before performing autolytic debridement?
-Lab values
What is the first step in managing excess bleeding?
-applying hard pressure for 10-15 minutes
What can you do to slow the rate of perfusion and prevent bleeding?
-Elevate the limb about the heart
What surgical procedure can be performed to stop excessive bleeding?
-Electro-caudery
What Is licalized damage to the skin and underying soft tissue usually over a boney prominence or related to a medical or other surface
-A pressure wound
How can a pressure wound present?
-as intact skin or an open ulcer
What is the authoritaive voice for pressure injuries?
-The NPUAP (National PRessure Ulcer Advisory Panel
What diagnosis has an increased liklihood of pressure injury?
-SCI, acute pediatrics, CVD and neonatal patients
What is the average cost to treat a full thickness pressure injury?
-$70,000
How can impaired lymphatic flow cause pressure injuries?
-causes the accumulation of metabolic waste products
How can repurfusion cause a pressure injury?
-by an inflammatory response due to return of blood to an ishemic area
What are the 4 proposed MOIs for pressure injuries?
-Ischemic, Reperfusion, Impaired lymphatic flow, and deformation of underlying tissue
How long does it take to for hyperemia to be observed with constant pressure?
-30 minutes
What are the clinical signs of hyperemia?
-Redness in the area up to 1 hour after the pressure is removed
How long does it take for tissue ischemia to occur under constant pressure?
-2-6 hours
What is a sign of tissue ischemia?
-Erythema; A dark red/purple color
How long does it take for necrosis to occur under constant pressure?
-6 hours
What is the final clinical step observed with pressure injuries?
-Ulceration
How long does it take for ulceration to occur?
-About 2 weeks
What type of wounds can you use the NPUAP scale to stage?
-ONLY pressure wounds
What is stage I of the NPUAP scale?
-nonblanchable erythema of intact skin
What is stage II of the NPUAP Scale?
-Partial thickness, with the dermis exposed; no signs of necrosis
How will a stage II pressure injury present?
-as an open shallow wound that is pinkish in color
What is a stage III pressure injury?
-Full thickness wound, no bone/tendon/fascia exposed with evidence of necrosis
What is a stage IV pressure injury?
-Full thickness with underlying structures exposed and necrosis
What is an unstagable pressure injury?
-When the wound cannot be staged prior to debridement
What is a suspected deep tissue injury?
-persistant, nonblanchable erythema and may be boddy of soft
What is a mucousal membrane pressure injury?
-Pressure injury on a mucous membrane with a history of medical device use
How do you stage a muscous membrane pressure wound?
-you cant
Stage I pressure ulcers account for what percent of pressure injuries in the geriatric population?
-47%
What are the risk factors for pressure injuries?
-Immobility, inactivity, sensory loss, shear friction force
What pressure injury risk assessment tool uses subscales of consistant physical condition, mental state, activity, mobility, and incontinence
-The norton scale
What is considered low risk on the norton scale?
-17 to 20
What is considered high risk for the norton scale?
-14 to 10
What is considered very high risk on the norton scale?
-Less than 10
