Other systems - Integumentary

Question 1

What are key functions of the integumentary system

Answer 1

Protection
 synthesis of vitamin D 
sensation 
thermal regulation
 excretion of sweat

Question 2

What are the phases of normal wound healing

Answer 2

Inflammatory phase 1 - 10 days
proliferative phase 3 - 21 days
maturation phase 7 days - 2 years

Question 3

What healing processes occur in the inflammatory phase of healing

Answer 3

Initial response to wound.
-Platelet activation and clotting cascade rapidly establish homeostasis.
- Necrotic tissue and debris and bacteria are moved by mast cells and neutrophils and leukocytes.
-Clean wound bed signals tissue restoration and repair to begin.
The epithelialization occurs in 24 hours, observed visible signs occur 3 days after

Question 4

Characteristics in the proliferative phase of healing

Answer 4

• Formaiton of new tissue signals proliferative phase.
• Epithelial cells migrate over wound bed created by new capillary beds and granulation tissue
• Keratinocytes, and epithelial cells, fiber fibroblasts are active and create collagen matrix.
• Skin integrity restored.
• Wound closure occurs via epithelialization and wound contraction.

Question 5

Characteristics of the maturation phase of food healing

Answer 5

• The scar begins to shrink and re-organize fibers and thin and contract scar
• Immature scars are red, raised, and rigid.
• Mature scars are pale flat and pliable.
• Scar tissue is remodeled/strengthened via collagen lysis and synthesis.
• For hypertrophic scarring can impact maturation phase progression, up to 2 years to reach maturity.
• Without hypertrophic scarring wounds typically mature in 4-8 weeks

Question 6

What is primary intention, secondary intention and tertiary intention

Answer 6

Primary intention; smooth clean edges (surgical incision, laceration, puncture, superficial/partial thickness wound) approximated with sutures, staples, adhesive. Min scarring, heal quick

Secondary intention: Wound closes on its own. Necrotic irregular or non-viable wound margins can’t be reapproximated. Infection or debris contamination. Diabetes, ischemic conditions pressure damage or inflammatory disease. much larger scars occur compared to primary intention

Tertiary intention: Delayed primary intention healing. Wound at risk for developing complications: sepsis or dehiscence are temporary left open. Risk factors: wounds with significant edema, debris contamination, high risk infection, questionable vascular integrity. Once risk factors decrease primary intention is used

Question 7

Factors that influence wound healing?

Answer 7

Age: epidermis thins and flattens with age, skin is more fragile and susceptible to injury from friction and sheer. Decreased rate of wound healing.

Co- morbidities: poor tissue perfusion in cardiovascular dx, DM, vascular conditions. Co-morb;s that suppress immune system can result in altered inflammatory process and healing.

Edema: some edema is normal. Altered hemodynamics via increased pressure form edema such as venous insiff, or lymphedema can result in poor perfusion and waste removal. increased risk of infection 2/2 poor O2 and nutrient delivery.

Harsh or inappropriate wound care: aggressive debridement and irrigation and chemicals, prolonged whirlpool, hurt granulation

Infection: immune responses are overwhelmed when bacteria compete for nutrients and release toxins that cause more damage

Life stlye: reg actiivty and good nutriaiton promote wound healing. Smoking results in hypoxia and increases infection risk

meds: anti-inflamatory, immunosupprisive, anticoagulant, anti neoplastic, steriod, birthcontrol, can negativky impact wound healing. poor/prolonged inflamatory repsonse, reduced BF, delayed collagen synthesis, decr tensile strength of repaired tissue
obesity: increased skin tension, susceptible to fissuring and therefore infection, large skin folds create moisture for bacteria growth and maceration.

Question 8

What are some types of burns that can occur ?

Answer 8

Thermal burn. Conduction or convection result from hot liquid fire or steam

Electrical burn.
Electrical current enters and exits of wound. Complications: arrhythmias, respiratory arrest, renal failure neurological damage, fracture.

Chemical burn. Acids

Radiation burn. DNA is altered due to external beam radiation. Comlications: Severe blistering desquamation, nonhealing wound, tissue fibrosis, permanent discoloration, new malignancies

Question 9

What are zones of injury for a burn ?

Answer 9

Zone of coagulation- Area of burn with most and irreversible damage

Zone of stasis. - Surrounds the zone of coagulation area is less severe and has reversible damage

Zone of hyperemia- Surrounds zone of stasis. Presents with information, will fully recover without permanent damage

Question 10

What is a superficial burn?

Answer 10

-Outer epidermis, slight edema and red

– heals without peeling or evidence of scarring in 2 – 5 days

Question 11

Superficial partial thickness burn

Answer 11

• Involves epidermis and upper portion of dermis.
• May be extremely painful, exhibit blisters.
• Healing minimal to no scarring 5- 21 days

Question 12

Deep partial thickness burn

Answer 12

• Complete destruction of epidermis and majority of dermis.
  – May appear discolored with broken blisters and edema.
  – Damage to nerves endings with moderate level of pain.
  – Hypertrophic or keloid scarring.
  – Without infection heals in 21-35 days

Question 13

Full thickness burn

Answer 13

Complete destruction of epidermis and dermis and partial damage to subcutaneous fat layer.

• Scar formation and minimal pain.
• Require grafts and susceptible to infection.
• Healing time varies with small areas healing in weeks with or without grafting.
• larger areas require grafts and months to heal

Question 14

Sub- Dermal burn

Answer 14

• complete destruction of epidermis, dermis and subcutaneous tissue.
• Involve muscle and bone.
• Require multiple surgical interventions and extensive healing time

Question 15

List the burn classifications from least severe to most severe

Answer 15

Superficial burn.
 Superficial partial thickness burn.
 Deep partial thickness burn.
 Full thickness burn. 
 Sub dermal burn

Question 16

How is iontophoresis related to Burns?

Answer 16

• Burns occur when pH increases or decreases beyond normal.
• Burns typically more severe under negative electrode due to pooling of alkaline solution.
• Skin erosion possible with reduced skin resistance reduced and increased electric current delivery
• Causes chemical burns: Excess current, prolonged duration, electrode placement over defective skin with lower resistance,
• Causes thermal burn: Poor electrode contact or increased impedance will create thermal burn f electrode if poorly placed

Question 17

What are examples of selective debridement

Answer 17

Sharp debridement.- Use of scalpel or similar device to remove large amount of thick, adherent necrotic tissue. Can be used for cellulitis or sepsis. Fastest way to remove necrotic tissue.

Enzymatic debridement- Topical application to remove necrotic tissue. Can be used on infected or not infected wounds with necrotic tissue. Can be used for wounds that do not respond to autolytic debridement or other techniques. Establishes clean wound bed.Discontinue when the devitalitized tissue is removed to avoid damage of healthy tissue.

Autolytic debridement- Use of bodies own mechanisms to remove nonviable tissue. Use of transparent films, hydrocolloids, hydrogels, and alginates. Moist wound environment rehydrates necrotic and eschar tissue, facilitates enzymatic digestion. Non-invasive and pain-free. Can be used with any amount of necrotic tissue and requires longer healing. Period not used on infected wounds

Question 18

What are examples of non-selective debridement

Answer 18

Wet to dry dressings
Wound irrigation
Hydrotherapy

Question 19

Sharp debridement

Answer 19

Sharp debridement.- Use of scalpel or similar device to remove large amount of thick, adherent necrotic tissue. Can be used for cellulitis or sepsis. Fastest way to remove necrotic tissue.

Question 20

Enzymatic debridement-

Answer 20

Enzymatic debridement- Topical application to remove necrotic tissue. Can be used on infected or not infected wounds with necrotic tissue. Can be used for wounds that do not respond to autolytic debridement or other techniques. Establishes clean wound bed.Discontinue when the devitalitized tissue is removed to avoid damage of healthy tissue.

Question 21

Autolytic debridement

Answer 21

Autolytic debridement- Use of bodies own mechanisms to remove nonviable tissue. Use of transparent films, hydrocolloids, hydrogels, and alginates. Moist wound environment rehydrates necrotic and eschar tissue, facilitates enzymatic digestion. Non-invasive and pain-free. Can be used with any amount of necrotic tissue and requires longer healing. Period not used on infected wounds

Question 22

Wet to dry dressings

Answer 22

Moistened gauze is placed over necrotic tissue and is removed when dry to remove adhered necrotic tissue adhered to gauze .
Used to do bride wounds with moderate amount of exudate and necrotic tissue.
Used sparingly on wounds with necrotic and viable tissue; granulation tissue is traumatized in process.
-Removal of dry dressings from granulation tissue may cause bleeding and pain

Question 23

Wound irrigation

Answer 23

Pulse lavage is an example. Desirable for wound infected or have loose debris. Pressure settings provide suction for removal of exudate and debris

Question 24

Hydrotherapy

Answer 24

Use of whirlpool. Can loosen it here in a crowded tissue. Not recommended.

Question 25

What is the red yellow black system

Answer 25

Red: pink granulation tissue goal: protect wound maintain moist environment Yellow, moist yellow slough. Goal remove exudate and debris absorb drainage. Black: black and eschar firmly adhered. Goals: debride necrotic tissue

Question 26

When would you use an alginate dressing? What are the advantages and disadvantages

Answer 26

- Highly absorptive highly permeable and non-inclusive. - Require second dressing. - Create hydrophilic gel through interaction of calcium ion in the dressing and sodium ions in the wound exudate. - Used on partial or full thickness draining wounds. Pressure or venous insufficiency ulcers. Used on infected wounds due to excess drainage. Advantages: high absorption capacity, automlytic debridement, protection from microbe contamination, Non-infected or not infected wounds, not adhering to wound. Disadvantages: frequent dressing changes based on drainage, requires secondary dressing, can't be used on wound with exposed tendon joint capsule bone

Question 27

When would you use a foam dressing dressing? What are the advantages and disadvantages

Answer 27

- Exudate is absorbed into foam. Commonly available in sheets or pads with various thickness. Semi permeable dressing produced in adhesive and non-adhesive forms. Non-adhesive require secondary dressing. - Used to provide protection and absorption for partial and full thickness wounds. Can be used as secondary dressings over amorphous hydrogels -Advantages: moist environment, available and adhesive and not adhesive forms, prophylactic protection and cushioning, encourages autolytic debridement, moderate resorption - Disadvantages - rolls in areas of excess friction, adhesive form can traumatize Perry wound with removal, lack of transparency; hard to inspect wound

Question 28

When would you use a gauze dressing? What are the advantages and disadvantages

Answer 28

Impregnated gauze uses Petrolatum zinc or antimicrobials. Use with infected or not infected wounds of any size. Used for wet to wet, wet to moist, or wet to dry debridement. -Advantages, Commonly available cost effective, can be used alone or in combination with other dressings or topical agents, multiple layers to accommodate changing wound status, can be used and infected or non infected wounds - Disadvantages Adheres to wound bed traumatizing viable tissue with removal, highly permeable, requires frequent changes, prolonged use decreases cost effectiveness, increased infection rate compared to occlusive dressing

Question 29

When would you use a Hydrocolloid dressing? What are the advantages and disadvantages

Answer 29

Gel forming polymers.Does not attach to wound, anchors to intact surrounding skin. Absorbs exudate by swelling in to gel like mass and varies in permeability thickness and transparency. Useful for partial and full thickness wound effective with granular or necrotic wounds - Advantages: Moist environment, enables autolytic debridement, offers protection from microbes, provides moderate absorption, does not require secondary dressing, waterproof surface - Disadvantages : Can traumatize skin upon removal, may roll in areas of excess friction can't be used in infected wounds

Question 30

When would you use a hydrogel dressing? What are the advantages and disadvantages

Answer 30

Available in sheet and amorphous forms. Used to retain moisture commonly used in superficial and partial thickness wounds (abrasion blister pressure ulcer) minimal drainage. - Advantages: Moist environment, enables autolytic debridement, may decrease pressure and pain, used as coupling agent for ultrasound, minimal wind adhesion, some products have absorbed of properties. - Disadvantages -potential for dressing to dehydrate, cant be used on words with significant drainage, requires secondary dressing

Question 31

When would you use a transparent film dressing? What are the advantages and disadvantages

Answer 31

Transparent film dressing with thin membrane and water resistant adhesive. Permeable to vapor and oxygen, and unpermeable to bacteria and water. Highly elastic, conform to body contour, allow for easy visual inspection of wound,Strength to sharing/friction forces, cost effective overtime. -Advantages Moist environment, enables autolytic debridement, can inspect wound, resistant to strength to sharing/friction forces, cost effective overtime. - Disadvantages can result in Peri wound maceration, adhesive may traumatized Peri wound with removal, can't be used on infected wounds

Question 32

List dressings from most occlusive to nonocclusive

Answer 32

``` most occlusive: Hydrocolloids, hydrogels. Semi permeable foam Semi permeable film Impregnated gauze Alginates nonocclusive: Traditional gauze ```

Question 33

Best dressings from most to least moisture retention

Answer 33

``` most moisture retentive: Alginate Semi permeable foam Hydrocolloids Hydrogels least moisture retentive:Semi permeable films ```

Question 34

Benefit does silver and iodine offer

Answer 34

Elemental broad spectrum antimicrobial agents used in dressings

Question 35

What is the relationship between incontinence and tissue injury

Answer 35

- urine and feces are acidic and can contribute to irritation in erosion of the skin. - Skin sheer and friction increase with mild - mod moisture. - Macerated skin has a decreased resilience to shear/friction - Avoid harsh cleansers hot water and scrubbing; will make delicate tissues friable. - Avoid irritation with mild cleanser, warm water, minimal friction. - Topical agents can act as barriers to excess moisture from incontinence and maintain natural moisture. - Emollient cream and ointments are better than water lotion. higher concentration of solid and oils requiring requiring less frequent application and better protection

Question 36

What bony prominences are associated with pressure injuries in supine

Answer 36

``` Occiput. Spine of scapula. Inferior angle of scapula. Vertebral SP. Humeral Medial epicondyles Posterior iliac crest Sacrum Coccyx Heel ```

Question 37

What bony prominences are associated with pressure injuries in prone

Answer 37

``` Forehead anterior AC joint Anterior head of humerus Sternum ASIS Patella Foot dorsum. ```

Question 38

What bony prominences are associated with pressure injuries in sidelying

Answer 38

``` Ears Lateral acromion process Lateral head of humerus. Humorous lateral of condyle Greater trochanter Head of fibula Lateral/medial malleolus ```

Question 39

What bony prominences are associated with pressure injuries in seated

Answer 39

Spine of scapula vertebral SP ischial tuberosity

Question 40

According to the rule of 9s, what is the adult value for the head and neck

Answer 40

9%

Question 41

According to the rule of 9s, what is the adult value for the anterior and posterior trunk ?

Answer 41

ant: 18% post: 18%

Question 42

According to the rule of 9s, what is the adult value for the BILATERAL anterior arm, forearm and hand ? The posterior arm, forearm and hand ?

Answer 42

anterior 9% | posterior 9%

Question 43

According to the rule of 9s, what is the adult value for the genital region ?

Answer 43

1%

Question 44

According to the rule of 9s, what is the adult value for the bilateral anterior leg and foot? The bilateral posterior leg and foot?

Answer 44

anterior 18% | posterior 18%

Question 45

what is the rule of 9s for a child?

Answer 45

if under 1 year, 9% is taken from LE and is added to the head/ neck region - each year of life, 1% id distributed back to LE until age of 9 when head is the same porpor as adult

Question 46

What is the wagner classification system ?

Answer 46

grades dysvascular ulcers based on depth and presence of infection - commonly used to assess diabetic foot ulcers, neuropathic, ischemic and arterial etiology

Question 47

Grade 0 on wagner scale

Answer 47

no open lesion | may have pre-ulcerative lesion, healed ulcer, bony deformity

Question 48

Grade 1 on wagner scale

Answer 48

- superficial ulcer not involving subcutaneous tissue

Question 49

Grade 2 on wagner scale

Answer 49

- deep ulcer with penetration of subcutaneous tissues, potentially exposes bone, tendon, ligament or joint capsule

Question 50

Grade 3 on wagner scale

Answer 50

- deep ulcer with osteitis, abscess or osteomyelitis

Question 51

Grade 4 on wagner scale

Answer 51

- gangrene of digit

Question 52

Grade 5 on wagner scale

Answer 52

- gangrene of foot reqs disarticulation

Question 53

what is stage 1 of pressure injury staging ?

Answer 53

non blanchable erythema of intact skin - color change does not include purple/ maroon - change in temp, sensation or firmness may proceed visible change - purple color may indicate deep pressure injury not ulcer

Question 54

what is stage 2 of pressure injury staging ?

Answer 54

partial- thickness skin loss with exposed dermis wound bed is pink, red, moist - can be intact or ruptured blister - adipose/deeper tissue isnt visible - granultion tissue: necrotic, or slough not present - occur commonly to adverse microclimate, shear - this stage does not define moisture assciated skin damage, incontinence associted dermatitis, intertriginous dermatitis

Question 55

what is stage 3 of pressure injury staging ?

Answer 55

full thickness skin loss - adipose is visable - granulation and epibole are often present - slough and eschar may be visable -undermining and tunneling may be present - fascia, tendon, mus, bone, ligament, cartilage are not visable -

Question 56

what is stage 4 of pressure injury staging ?

Answer 56

full thickness skin and tissue loss - exposed or directly palpable bone, fascia, mus, tendon, lig, cartilage in ulcer - can have slough and eschar - epibole undermining and tunneling may be present

Question 57

what is an unstageable ulcer

Answer 57

obscured by necorioc tissue or slough - if slough or eschar can be removed, it can be defined at stage 3 or 4 - stable eschar shouldnt be removed from heel or ischemic limbs

Question 58

what is a deep tissue pressure injury

Answer 58

persistent non blanchable deep red, maroon, or purple discoloration - results from intense or prolonged pressure and shear F at bone mus interface - can be in intact or non-intact skin - do not use this to describe, vascular, traumatic, neuropathic or dermatologic conditions

Question 59

is serous drainage normal ?

Answer 59

yes , during the inflammatory and proliferative phases of healing

Question 60

What does sanguineous drainage indicate?

Answer 60

broken or new blood vessels

Question 61

is serosanguineous drainage normal ?

Answer 61

yes light red or pink with watery consistency normal in healthy healing wound and seen in inflammatory and proliferative phases

Question 62

are seropurulent and purulent normal ?

Answer 62

no | always abnormal in wound

Question 63

What is the difference between penetrating any puncture acute wound

Answer 63

Penetrating: wound that enters interior of organ or cavity. Puncture: sharp object penetrate skin and underlying tissue. Risk of contamination and infection significant.

Question 64

When do arterial insufficiency ulcers occur

Answer 64

Results from arterial insufficiency secondary to an adequate circulation of blood/oxygen. Ischemia. Due to complicating factors; arthrosclerosis

Question 65

What are general recommendations for arterial insufficiency ulcers

Answer 65

``` Rest. limb protection. Risk reduction education. Feet and leg inspection daily. Avoid leg elevation. Avoid heating pad and soaking feet. Wear appropriately size shoes with clean seamless socks. ```

Question 66

When do Venous insufficiency ulcers occur

Answer 66

Secondary to impaired function of Venous system. Results in an adequate circulation tissue damage and ulceration

Question 67

What are general recommendations for Venous insufficiency

Answer 67

limb protection. Risk reduction education. Feet and leg inspection daily. compression to control edema. Elevate legs above heart when resting and sleeping. Attempt to active exercise and frequent ROM. Wear appropriately size shoes with clean seamless socks.

Question 68

What causes neuropathic ulcers to occur.

Answer 68

Secondary complication associated with combo of ishemia and neuropathy. Associated with DM, but any form of peripheral neuropathy has risk for wound development

Question 69

What are general recommendations for neuropathic ulcers

Answer 69

``` limb protection. Risk reduction education. Feet and leg inspection daily. look at feet b4 donning Wear appropriately size shoes with clean seamless socks. ```

Question 70

What causes pressure ulcers

Answer 70

Decubitus ulcers result from sustained/prolonged pressure on tissue greater than capillary pressure. Bony prominences prominences are susceptible to localize ishemia and tissue necrosis. - Shearing force, moisture, heat, friction, medications, muscle atrophy, malnutrition, debilitating medical conditions contribute to pressure ulcers - We can scale and Norton scale are assessments.

Question 71

What are general recommendations for pressure ulcers

Answer 71

``` Reposition every two hours. Manage moisture. Offload pressure with devices. Daily skin inspection. Limit sheer traction and friction forces over fragile skin ```

Question 72

What are characteristics of an arterial insufficiency ulcer

Answer 72

Location. -Lower 1/3 of leg, toes, Webb space. Appearance. - Smooth edges, well defined, deep Exudate- min Pain- severe Pulses- absent or low Edema. Normal Temperature- decreased Tissue change-thin and shiny, hair loss, yellow nails Other - leg elevation increases pain

Question 73

What are characteristics of an venous insufficiency ulcer

Answer 73

``` Location. Proximal medial malleolus. Appearance. - shallow and irregular shape Exudate- mod-heavy Pain- mild-mod Pulses- normal Edema- increased Temperature-normal Tissue change- flaky dry skin, brown Other - leg elevation decreases pain ```

Question 74

What are characteristics of an neuropathic ulcer

Answer 74

Location. Foot areas susceptible to pressure or sheer force during weight-bearing Appearance- well defined oval or circle. can have callus border. Exudate- min Pain- low Pulses- absent or low Edema- normal Temperature-decreased Tissue change- dry inelastic, decreased or absent sweat and oil production Other- loss of protective sensation.