Quiz 1: Lecture 1-4 Flashcards
List the layers of the skin from superficial to deep
Epidermis, dermis, subcutaneous tissue (hypodermis)
PT decision making consists of…
Refer, consult, co-manage, retain
What are the 5 layers within the epidermis?
Stratum corneum, Stratum lucidum, Stratum granulosum, Stratum spinosum, Stratum basale
Describe the epidermis
- The tough, leathery outer surface of the skin ranging in thickness from .06 to .6mm
- Contains 5 sub layers
- avascular (no blood supply)
Which layer is found between the stratum basale (lowest layer of epidermis) and and dermis?
Basement membrane
Which of the following is not a function of the integumentary system?
- excretion
- production of blood cells
- temperature regulation
- protection
- sensory reception
- vitamin D production
Production of blood cells
What material gives the epidermis the ability to resist abrasion and reduce water loss?
- keratin
- melanin
- carotene
- dermal papillae
Keratin
What structures of the epidermis are responsible for detecting light touch?
- Langerhans cells
- Merkel cells
- Keratinocytes
- Melanocyte cells
merkel cells
List the correct layers of the epidermis from superficial to deep
- Stratum Corneum
- Stratum Lucidum
- Stratum Granulosum
- Stratum Spinosum
- Stratum Basale
Having 1-2 layers of cells closest to the basement membrane and rapid mitosis is a feature of which layer of the epidermis?
Stratum Basale
Having 8-10 layers of cells filled with keratin fibers and a “prickle” appearance is a feature of the…
Stratum Spinosum
Which layer is found only in thick skin?
Stratum Lucidum
The most superficial layer of the skin, having more than 25 layers or more of dead squamous cells with keratin is called…
Stratum Corneum
Skin pigments produced by cells are called…
melanocytes
The hypodermis is primarily made of what?
Adipose tissue
What are 3 clinical reasoning processes?
- Forward reasoning process (Pattern Recogntion)
- Backward reasoning process (Hypothetico-deductive process)
- Hypothesis oriented algorithm for clinicians
What are the components of PT examination
- History of present illness
- History questions
- General demographics + subjective info
- Systems Review (pulmonary, cardiovascular, musculoskeletal, neuromuscular, integumentary)
What are the 4 main purposes of a systems review
- Identify referral need
- Identify risk factors/impairments
- Identify signs and symptoms consistent with different disease processes
- Determine educational needs
What is the SMART pmnemonic?
S - Specific
M - Measureable
A - Attainable
R - Realistic
T - Time related
What are the components of a clinical summary (Eval)
- tests and measures
- Integrates the test and measures data with other information collected during the history and systems review
- diagnosis
- prognosis
Describe the skin in terms of its size and weight contribution to the body
The skin is the largest organ of the body, accounting for approximately 15% to 20% of total body weight.
How does the thickness of skin vary across different body parts?
Skin thickness varies from 0.5mm on the eyelids to 8mm on the soles of the feet.
How often are skin cells replaced?
Every 15-30 days
What are the protective functions of the skin?
The skin protects against trauma, prevents bacterial and viral penetration, and guards against physical and chemical damage.
T or F? The skin plays a crucial role in regulating body temperature
True
What types of sensory reception does the skin provide?
pain, touch, temperature, and pressure.
Which layer of the skin produces vitamin D?
Epidermis
What is the basement membrane?
A thin layer under epithelial cells that provide structural support
How thick is the epidermis and what is its vascularity?
The epidermis is 0.06 to 0.6 mm thick and is avascular.
Identify the primary cell type found in the epidermis
The primary cell type in the epidermis is keratinocytes, which make up 90% of the cells
List the other cell types found in the epidermis besides keratinocytes.
Melanocytes, merkel cells, langerhan cells
How long does it take cells to move from stratum basale to stratum corneum
15 to 30 days.
What are the 3 phases of wound healing?
- Hemostasis (not a true phase)
- Inflammation
- Proliferation
- Maturation
Describe the dermis layer of the skin.
- thickest layer of the skin (2 to 4 mm)
- less defined layers compared to the epidermis
- highly vascular and contains various cells such as fibroblasts, macrophages, mast cells, and white blood cells.
How many layers does the dermis have and what are they primarily made of?
2, the papillary dermis and the reticular dermis (primarily made of collagen and elastin)
Define the papillary and reticular layers of the dermis.
- papillary dermis is the upper layer of the dermis
- while the reticular dermis is the thick/dense lower layer (makes up 80% of the dermal thickness)
What types of sensory organs are housed in the dermis?
The dermis houses sensory organs that detect touch, pressure, vibration, and temperature.
List the appendages contained within the dermis.
The dermis contains dermal appendages such as hair follicles, sweat glands, sebaceous glands, and nails
What is the function of sebaceous glands in the dermis?
Sebaceous glands create sebum which lubricates and protects the skin
How does the dermis contribute to the skin’s structure?
- Provides strength and elasticity through its collagen and elastin fibers
- Houses various appendages and sensory organs
What types of white blood cells are found in the dermis?
neutrophils, basophiles, and eosinophils
Describe the appearance of healthy dermal tissue.
smooth, even texture and a consistent color (indicates good blood flow and proper function)
Define the primary purpose of the subcutaneous layer (hypodermis).
primarily for energy storage, as it is composed of loose connective tissue and fat cells.
Which vitamins are stored in the subcutaneous layer?
fat-soluble vitamins A, D, E, and K.
How does the subcutaneous layer support the dermis?
The subcutaneous layer anchors the dermis, providing stability and support to the skin structure.
T or F? The subcutaneous layer is highly vascular
True
Do all wounds heal at the same rate?
The process of repair is the same for all wounds; however, healing times will vary due to certain factors.
What is transudate fluid and its role in hemostasis?
Transudate fluid decreases vessel pressure and contributes to local edema during the hemostatic response.
How does vasoconstriction affect blood flow during hemostasis?
a short-term decrease in blood flow to the affected area.
Define the role of platelet aggregation in hemostasis.
involves the clumping of platelets and the activation of clotting factors, leading to the deposition of fibrin.
What is the significance of fibrin?
Fibrin is deposited to form a clot, which helps prevent contamination and provides a mesh structure for wound healing.
Describe the Inflammation Phase in wound healing.
- 0 to 4 days after injury
- causes redness, heat, edema, pain, and loss of function.
- Histamine is released by mast cells, and skin grafting is often performed during this phase.
- platelets, PMNs, macrophages, mast cells
How does histamine contribute to the Inflammation Phase?
promotes vascular responses that lead to increased blood flow and permeability, contributing to the classic signs of inflammation.
Define the goals of the Inflammation Phase in wound healing.
- providing hemostasis
- bringing white blood cells (neutrophils and macrophages) into the wound
- recruiting matrix metalloproteases (MMP) to break down debris
- providing a clean wound site for tissue restoration.
What role do neutrophils and macrophages play in the Inflammation Phase?
Neutrophils and macrophages are white blood cells that are recruited to the wound site during the Inflammation Phase to help clear debris, fight infection, and facilitate the healing process.
When does skin grafting occur?
0 to 4 days after injury (inflammation)
Describe the role of platelets in the inflammatory phase
Releases growth factors and signaling molecules to help initiate the inflammatory response during the hemostasis phase
Define polymorphonuclear neutrophils (PMNs) and their function in inflammation phase
a type of white blood cell that plays a crucial role in the immune response by destroying pathogens during the inflammatory phase.
How do macrophages contribute to the inflammatory phase?
Macrophages help by phagocytosing pathogens and debris, releasing cytokines to recruit other immune cells, and facilitating tissue repair.
What is the function of mast cells in inflammation phase?
release histamine and other chemicals that promote vasodilation and increase blood flow to the affected area during inflammation.
List the 5 cardinal signs of inflammation.
redness, heat, swelling, pain, and loss of function.
Do macrophages work similar to “pacman”?
Yes, macrophages are like pacman as they actively engulf and digest cellular debris and pathogens in a manner similar to how pacman consumes dots
Describe the function of the Dermis.
The Dermis supports the epidermis with nutrition and structure, assists with prevention of infection, and protects us directly from UV light.
What are the 4 cells of the inflammation phase? (KNOW THIS)
- Platelets
- Polymorphonuclear neutrophils (PMNs)
- Macrophages
- Mast cells
What happens if the inflammatory phase is interrupted?
It becomes chronic inflammation
What are the 4 sub-phases of the proliferation phase?
Angiogenesis, granulation tissue formation (collagen synthesis), contraction, epithelialization
What are the 4 types of cells in the proliferation phase?
Angioblasts, Fibroblasts, Myofibroblasts, Keratinocytes
What do angioblasts do?
Form new blood vessels
What do fibroblasts do?
contributes to the formation of connective tissue
What do myofibroblasts do?
mediate wound contractions
What do keratinocytes do?
Forms a protective barrier on the skin by producing keratin
What happens during angiogenesis of the proliferation phase?
Formation of new blood vessels are from pre-existing vasculature
What happens during the granulation formation subphase of the proliferation phase?
granulation tissue is formed (collagen synthesis)
What happens during the contraction subphase of the proliferation phase?
Wound edges pull in towards the center and it begins to close
What happens during the epithelialization subphase of the proliferation phase?
keratinocytes migrate and replicate to cover a defect on the surface
what is the primary cell of the granulation subphase of the proliferation phase?
fibroblasts
Describe hyper-granulation.
Hyper-granulation is an abnormal response characterized by tissue that resembles jelly, bleeds easily, and progresses above and beyond the level of the wound.
T or F? Contraction is fastest when the wound is a straight line, rather than rectangular (moderate speed) or circular (slow speed) wounds
True
What is the greatest amount of contraction observed in wound healing?
The greatest amount of contraction occurs with full-thickness wounds, resulting in approximately a 40% decrease in size.
What environmental conditions are necessary for optimal wound contraction?
A warm environment with high oxygen levels and adequate nutrition is necessary for optimal wound contraction.
List essential nutrients for wound healing.
Zinc, iron, copper, and vitamin C are essential nutrients for wound healing.
Describe hypo-granulation in chronic wounds.
Hypo-granulation refers to the inability of the wound to fill the defect, often seen in patients with diabetes mellitus or malnutrition.
What is epibole?
When a wound has round edges (often leads into a chronic wound)
What is the significance of scar tissue in the remodeling phase?
Scar tissue is built to provide increased tensile strength, initially at 15-20% of the original strength, eventually reaching about 80%.
Explain the concept of ‘second generation’ scar strength.
A ‘second generation’ scar refers to scar tissue that achieves approximately 64% of the original tissue strength.
How long does the remodeling phase last after an injury?
The remodeling phase can last up to 2 years post-injury.
What occurs to old collagen during the remodeling phase?
During the remodeling phase, old collagen is broken down as new collagen is synthesized to maintain a low scar mass.
Describe the changes that occur in scar maturation.
Cellularity and Vascularity decrease, leading to a transition from pink to grey color and bulky to flat appearance
Define the types of collagen involved in scar formation.
Scar formation involves the transition from immature Type III collagen to mature Type I collagen during the maturation phase.
What happens to the cellularity of a scar as it matures?
as it matures, cellularity decreases from high to low, leading to a flattening of the scar.
How much more likely are individuals with darker skin to develop keloids?
darker skin is 15x more likely to develop keloids compared to those with lighter skin.
What is the difference between hypertrophic scars and keloid scars?
Hypertrophic Scars: raised scars that do not extend beyond the original wound
Keloid Scars: extend beyond the wound margins and can continue to grow (huge scars)
Which layer of the skin houses sensory organs? Epidermis or Dermis
Dermis
Which layer of the skin houses keratinocytes? Epidermis or Dermis
Epidermis
Which layer of the skin houses 2 layers? Epidermis or Dermis
Dermis
Which layer of the skin is thinner? Epidermis or Dermis
Epidermis
Which layer of the skin contains hair follicles? Epidermis or Dermis
Dermis
What is the purpose of the hypodermis?
Thermoregulation/insulation, store energy and fat soluble vitamins (A, D, E, K), anchors the dermis, supports muscles, bones, fascia
What are the 5 classic signs of inflammation?
Erythema (redness), loss of function, pain, heat, edema (swelling)
What is the first stage of wound healing? Immediate response? Time period? What is released? Important cells? Goals? Disrupted by?
Inflammation Phase
Immediate response: Hemostasis
Time Period: 0-4 days
What is released?: Histamine
Important cells: Platelets, PMNs, Macrophages, Mast cells
Goals: Stop bleeding + bring cells to clean the wound
Disrupted by: Vascular insufficiency
What is the second stage of wound healing? Sub phases? Time period? Important cells? Goals? What could go wrong?
Proliferation Phase
Sub phases: Angiogenesis, granulation, contraction, epithelialization
Time Period: 2 days - 2+ weeks
Important cells: Angioblasts, fibroblasts, myofibroblasts, keratinocytes (blast = build)
Goals: Fill in wound with granulation tissue
What could go wrong?: Hypergranulation, hypogranulation, epibole, etc.
What is the third phase of wound healing? Time period? What is synthesized? What could go wrong?
Maturation Phase
Time period: 24 days - 2 years (peaks at 6 months)
What is synthesized?: Collagen
What could go wrong?: Dehiscence, hypertrophy, keloid
What is the tensile strength of a first generation scar? second generation?
1st Generation Scar: 80%
2nd Generation Scar: 64%
Differentiate between early and late stage scars
Early:
- High Vascularity
- High Cellularity
- Type III Collagen
- Random Layers
- Red/Pink Coloration
Late:
- Low Vascularity
- Low cellularity
- Type I Collagen
- Organized Fibrils
- Pale White Coloration
What is the difference between a keloid and hypertrophic scar?
Keloid Scar: Spans outside the borders of incision, higher in type III collagen than hypertrophic
Hypertrophic Scar: Remains within the border of incision, collagen ratio 2 (type I) : 1 (type III)
How do you know if a scar can still be managed/changed?
If it is still red, puffy, blanching, usually peaking in the first 6 months
What is the collagen ratio in normal skin?
(type I) 4:1 (type III)
What is the collagen ratio in hypertrophic scars?
(type I) 2:1 (type III)
Which type of scar is higher in type III collagen, Keloid or Hypertrophic?
Keloid scar
What are some methods of scar management?
compression, massage (based on tension theory), steroids, and surgical interventions.
Which medications affect wound healing?
- NSAIDs
- steroids
T or F? When oxygen pressure (PO2) is <40mmHg, collagen synthesis is heavily impacted
True
What is the most common cause of wound infection?
Decreased PO2
What are the 3 types of wound closures?
1.) Primary Closure
2.) Secondary Closure
3.) Delayed Primary Closure
What is primary wound closure (primary intention)?
- Wound closes with surgical intervention (has clear edges)
- Closes within 7 days
- Leaves minimal to no scarring
- Potential for dehiscence (when surgical wound re-opens)
What is dehiscence?
When a surgical wound re-opens
What is secondary closure (intention)?
- Closes naturally
- A wound that penetrates through the epidermis and into the dermis
- Heals by contraction (and some granulation + re-epithelialization)
- Involves scar tissue formation
What is delayed primary closure (tertiary intention)?
- A wound that begins to heal naturally (secondary intention), then finished with surgical closure (primary intention)
- Can be kept open for 4-6 days, then closed by surgical intervention
Reasons for this?
- Large amount of tissue loss/swelling
- Contamination
- High risk of infection
What is the “marion” wound healing scale?
A color wound classification system
- Red, yellow, black
What is the “wagner” scale?
Used to classify neuropathic, ischemic, and arterial ulcers on a 0-5 scale
Why does a wound become chronic in the inflammatory phase?
- lack of stimulus for repair
- inadequate perfusion and ischemia
- free radicals and O2 reperfusion injury
What are the collagen ratios in normal skin, hypertrophic scars, and keloid scars?
Type I : Type III
Normal skin - 4:1
Hypertrophic scars - 2:1
Keloid scars: Even higher type III collagen
Which phase may have endothelial buds?
Proliferation phase (angiogenesis to be exact)
What does slough tissue look like?
yellow or white (strings or thick clumps)
What does granulation tissue look like?
- pink/red
- shiny and moist
- granular appearance
What does epithelial tissue look like?
- New pink + shiny tissue
- grows in from the edges
What does necrotic tissue look like?
Black, brown, or tan
What is a periwound?
The skin located around the wound itself
What is maceration?
softening of tissue from liquid
What is anhydrous?
dry, cracked, or scaly skin
What is tunneling?
The separation of fascial layers between the muscles under the skin
What does it mean when the periwound is undermining?
An area of tissue destruction extending under the skins edges
List the functions of the skin
- excretion
- temperature regulation
- protection
- sensory reception
- vitamin D production
T or F? Zinc, iron, copper and vitamin C are essential during the contraction phase
True
What are platelets?
Small cells that help to stop bleeding
What are polymorphonuclear neutrophils (PMNs)?
A type of white blood cell that plays a big role in the immune system by responding to infection and tissue damage through phagocytosis
T or F? Macrophages and neutrophils are white blood cells (WBC)
True
What are macrophages?
A type of WBC that kills microorganisms and removes dead cells
What are mast cells?
A type of WBC that fights infection and regulates immune responses
What is vitamin B12?
Helps with anemia, produces red blood cells
What is vitamin A?
Assists with inflammation
What is vitamin D?
Bone health
What is vitamin E?
Fat metabolism
What is vitamin K?
coagulation and heart health
What is vitamin C?
Skin health
What is Zinc?
Infection control
What is iron?
Blood and red blood cells
What is copper?
Helps with cell development
T or F? Full thickness wounds cause a loss of dermal appendages
True
During the vascular response all of the following are part of that response except
a. Decreased vessel pressure
b. Vasoconstriction
c. Inflammation
d. Platelet aggregation
Inflammation
What do platelets do?
Help with clotting
What do mast cells do?
- Release histamine
- Immune response
- Help fibroblast proliferation
What do PMNs do?
removes damaged tissue
What is the primary cell in the granulation formaton subphase?
Fibroblast
What type of cells must be in the would in order for epithelialization to occur correctly
a. Dry
b. Granulated
c. Non-viable
d. Necrotic
granulated
T or F? An epibole is a sign of a chronic wound
True
T or F? During the maturation phase, a scar starts at random layers and Type I collagen and
matures into organized fibrils with Type III collagen
False – the scar starts as random layers of TYPE III (immature) collagen
What happens if collagen synthesis is impaired?
Impaired tensile strength and increased risk of dehiscence
A primary wound closure should take how many days to close?
7
Describe the wagner scale
0 – no open lesion, may have cellulites
1 – superficial ulcer/partial thickness
2 - deep ulcer to tendon or bone
3 – deep ulcer with abscess or osteomyelitis
4 – localized gangrene
5 – gangrene of the entire foot
What does histamine (released from mast cells do?
signals for more inflammation
T or F? use silver on infected wound
True
