SD Day 5 Flashcards by Ian Christopher Mangaoang

Avascular layer of the skin

epidermis

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What are the 5 layers of the epidermis

Come Let’s Get Sun Burned

Corneum 
Lucidum 
Granulosum 
Spinosum 
Basale

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This considered to be the true skin

Dermis

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Two Layers of the Dermis

Papillary and Reticular

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This layer of the Dermis is composed of Meissner’s Corpuscles and Free nerve endings

Papillary Layer of the Dermis

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This layer of the Dermis is composed of Collagen, Elastin and reticular fibers

Reticular Layers of the Dermis

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Free nerve endings in the epidermis mediate what type of sensation?

Pain and Itch

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Free nerve endings in the dermis mediate what type of sensation?

Pain

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Merkel’s Disks in the Stratum Spinosum mediate what type of sensation?

Touch

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Meissner’s Corpuscles in the papillary dermis mediate what type of sensation?

Touch

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Ruffini’s corpuscles in the papillary dermis mediate what type of sensation?

Warmth

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Krause’s end bulb in the papillary dermis mediate what type of sensation?

Cold

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Pacinian corpuscles in the reticular dermis mediate what type of sensation?

Pressure and vibration

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This layer of the skin is mostly composed of loose connective tissue and and fat tissue

Subcutaneous Tissue

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This layer of the skin functions as insulation, support, cushioning and regulation of temperature of the skin.

Subcutaneous Tissue

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This is itching of the skin

Pruritus

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Local redness and eruption of the skin

Rash

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These are smooth slightly elevated patches on the skin

Urticaria

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This is excessive dryness of the skin characterized by scaly desquamation

Xeroderma

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This is the degree of elasticity of the skin.

Turgor

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Normal Skin Turgor is (in seconds)?

4 seconds

abnormal = 5 seconds or more

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What are the 2 factors that affect skin turgor

dehydration and aging

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Pitting edema indicates?

Chronis Venous Insufficiency

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Non-pitting edema indicates?

Brany edema (inflammation of the subcutaneous layer of the skin)

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This is an indicator of the hepatic system, presenting with yellowing of the eye and skin.

jaundice

If bilirubin levels reach 2-3mg/dl where will jaundice present?

sclera of the eyes

If bilirubin levels reach 5-6 mg/dl where will the jaundice present?

Sclera of the eyes and the Skin

Change of lips change to cherry red this is an indication of what type of poisoning?

Carbon monoxide poisoning

Patchy Tan to Brown spots is a common skin change in what disease?

Addisons Disease

Temporary pallor occurs in what conditions?

Arterial Insufficiency, Syncope, chills and shock

This is thin depressed nails with lateral edges tilted upward forming a concave profile. AKA Spoon Nails

Koilonychia (common with iron deficiency)

Splinter nails is an indication of what type of condition?

Silent MI, Endocarditis and vasculitis

This is infection of the skin fold of skin at the margin of the nail (fungal infection from wet work)

Paronychia

Loosening of the nail plate, usually from the tip of the nail, progressing inward and from the edge of the nail moving inward.

onychylosis

What the conditions where onychylosis is often see?

Grave's Disease, psoriasis, reactive arthritis and obsessive compulsive behaviors

Type of nails change where in lunula's cannot be seen and have a "ground glass" appearance

Nails of Terry

Conditions where Nails of Terry are often seen

Liver Pathology, DM. Hyperthyroidism

white spots on nails, often associated with trauma, hypocalcemia, Hodgkin's dse, renal failure, MI and malnutrition from eating disorders.

Leukonychia

These are transverse lines on nails

Beau's Lines

Consecutive transverse lines of the nails, indicative of renal and cardiac failure, MI, Hodgkins dse, and sickle anemia.

Mee's Lines

Proliferation of melanocytes, round, or oval shaped, sharply defined borders, uniform color, <6mm, flat or raised.

Common Mole (benign nervous)

Raised lesions due to proliferation of basal cells. Yellowish to brown in color with greasy, velvety and warty texture.

Seborrheic keratosis

Slow growing, raised patch with an ivory appearance, rolled border with indented center / thickened area of skin • On hair bearing sun exposed areas (face, neck, ears, hands)

Basal Cell carcinoma

Poorly defined border, flat red area, ulcer, or nodule, sun exposed areas (ear, face, lips, mouth, hand dorsum) Central part may be ulcerated, scaly or crusted No Metastasize* Fairly skinned individuals > 60 y/o

Squamous cell carcinoma

* Most serious skin cancer * Arising from Melanocytes * Associated with intensity > duration of sunlight exposure * Nevi that are changing or atypical, especially if >50 * Can cause pain, swelling, bleeding or sensation of itching; burning.

Malignant Melanoma

- Inflammation of the skin | - Skin is red, brown or gray; sore itchy and swollen

Dermatitis

Three Causes of Dermatitis

- Allergic/contact dermatitis: poison ivy, harsh soaps, chemicals - Actinic: photosensitivity - Atopic: etiology unknown, associated with allergic, hereditary, or psychological disorders

stage of dermatitis where there is red, oozing, crusting rash, extensive erosions, exudate, pruritic vesicles

Stage 1: Acute

stage of dermatitis where erythematous skin, scaling, | scattered plaques

Stage 2: Subacute

stage of dermatitis where thickened skin, increased skin marking secondary to scratching, post- inflammatory pigmentation changes

Stage 3: Chronic

* Development of areas of very dry, thin skin and sometimes shallow ulcers of the lower legs primarily as a result of venous insufficiency * History of varicose veins or deep vein thrombosis

Stasis Dermatitis

* Chronic facial skin disorder seen most often in adults between the ages of 30 and 60 years * Erythema, flushing, telangiectasia, papules, and pustules affecting the cheeks and nose of the face. * Enlarged nose is often present

Rosacea

- Benign fatty fibrous yellow plaques, nodules, or tumors that develop in the subcutaneous layer of skin - Most often associated with disorders of lipid metabolism, primary biliary cirrhosis, and uncontrolled diabetes - May have no pathologic significance but can occur in association with malignancy such as leukemia, lymphoma, or myeloma

Xanthomas

- Superficial skin infection caused by staphylococci or streptococci - Inflammation, small pus-filled vesicles, itching - Contagious - Common in children and the elderly

Impetigo

❑ Suppurative inflammation of cellular or connective tissue in or close to the skin ❑ Poorly defined and widespread ❑ By streptococcal or staphylococcal infection ❑Can be contagious ❑ Skin is red, hot and edematous ❑ Can lead to lymphangitis, gangrene, abscess and sepsis

Cellulitis

- Itching and soreness followed by vesicular eruption on the face or mouth - Aka cold sore, recurrent herpes labialis, fever blister

Herpes 1 (Herpes Simplex)

❑ Common cause of vesicular genital eruption ❑Spread by sexual contact ❑Aka genital herpes

Herpes 2

❑Painful infection of the terminal phalanx caused by Herpes Simplex 1 and 2 ❑Tingling pain or tenderness of the affected digit followed by throbbing pain, swelling and redness

Herpetic Withlow

❑Caused Varicella-zoster virus (chicken pox) ❑Pain and tingling affecting spinal or cranial nerve dermatome ❑Red papules progressing to vesicles ❑Accompanied by fever, chills, malaise, GI disturbances ❑(+) Post herpetic neuralgic pain

Herpes Zoster (Shingles)

o Highly contagious, spread from person to person by direct contact o Sores occur at the site of infection, mainly on the external genitals, vagina, anus, or rectum. o Sores can also occur on the lips and in the mouth o Transmission occurs during vaginal, anal, or oral sex

Sphyphilis

❑ Benign infection by human papilloma virus (HPV) ❑ Transmission: direct contact and autoinoculation (via broken skin) ❑ Location: hands and fingers ❑ Plantar wart: on pressure points of the feet

Warts

* Forms ring-shaped patches with vesicles or scales * Transmission is direct contact * Treatment: Topical or antifungal drugs

Ring worm (Tinea Corporis)

* Erythema, inflammation, pruritis, itching, pain * Can progress to cellulitis if untreated * Treatment: Antifungal creams

Athlete’s foot (Tinea Pedis)

Presence of fungal infection on the beard

Tinea Barbae

Presence of fungal infection on the Scalp

Tinea Capitis

Yeast type of fungal infections

candidiasis

- Bacterial infection carried by bacteria | - (+) Bulls eye appearance

Erthema Chronic Migrans (Lyme's Disease)

❑ Chronic disease of skin with erythematous plaques covered with silvery scales ❑ Common in ears, scalp, knees, elbows, genitalia, extensor surfaces ❑ Associated with psoriatic arthritis, joint pain ❑ Topical meds may be used ❑ PT Intervention: UV light with psoralens

Psoriasis

❑ Chronic, progressive inflammatory disorder of connective tissues ❑ Characteristic red rash with raised red, scaly plaques

Lupus Erythematosus

❑ Affects only skin; flare-ups with sun exposure ❑ Causes atrophy, permanent scarring, hypo/hyperpigmentation

DISCOID LUPUS ERYTHEMATOSUS (DLE)

❑Chronic, systemic inflammatory disorder affecting multiple organ systems ❑Can be fatal ❑Symptoms: Fever, butterfly rash across bridge of nose, arthritis, photosensitivity, Raynaud’s Phenomenon

Systemic Lupus Erythematosus

Chronic, autoimmune diffuse disease of connective tissues causing fibrosis of skin, joints, blood vessels, GI tract, lungs, heart, kidneys

Scleroderma

❑ Affecting the connective tissues ❑ Inflammation of the muscle and skin ❑ Skin rash and proximal mm weakness ❑ (+) Gottron's sign ❑ (+) Heliotrope rash ❑ (+) Shawl sign ❑ (+)Mechanic’s Hands

Dermatomyositis

AKA Lilac Rash

Heliotrope Rash

* Skin is not broken | * Pain, swelling and discoloration

Contusion

Bluish discoloration of skin caused by extravasation | of blood into subcutaneous tissues

Ecchymosis

Tiny red or purple hemorrhagic spots on the skin

Petechiae

Scraping away of skin as a result of injury or mechanical abrasion

Abrasion

Irregular tear of the skin producing torn, jagged wound

Laceration

- lack of pigmentation | - usually on sun-exposed areas, body folds, and around openings

Vitiligo

light brown macules Diagnosis: >5 lesions or 1 lesion but >1.5 cm

Cafe-au-lait

What are the 3 zones of burns?

Zone of Coagulation Zone of Stasis Zone of Hyperemia

A 45 year old male presents to the burn unit with partial thickness burns over the entire right arm, left arm, front of head, and front of the abdomen. Approximately what percentage of his body is burned? A. 31.5% B. 36% C. 40.5% D. 45%

C. 40.5%

Burn affecting epidermis only, pink or red with No Blisters, tenderness and minimal edema

Superficial Thickness Burn (First Degree)

Degree of burn where wound is insensitive to light touch or soft pin prick

Deep Partial Thickness Burn

Burns where the affected structures are epidermis and upper layers of dermis with Bright red/pink, intact blister

Superficial Partial Thickness Burn

Complete destruction of epidermis, dermis and subcutaneous tissues, may extend into muscles

Full-thickness Burn (third degree)

Most Painful Type of Burn

Superficial Partial Thickness Burn

White, gray, charred, black, poor distal circulation, parchment-like, dry leathery surface Little pain, destroyed nerve endings

Full-thickness Burn (third degree)

Complete destruction of epidermis, dermis and subcutaneous tissues, with muscle damage May lead to necrosis

Subdermal Burn (fourth degree)

Broken blisters (moist) Marked edema, sensitive to pressure

Deep Partial- thickness Burn (second degree)

What is the most common mechanism of injury for subnormal burns?

Electrical Burns

Stage of dermal healing: stop the bleeding by initiating coagulation

Hemostasis and degeneration

Stage of dermal healing: Redness, edema, warmth, pain and decreased range of motion

Inflammatory phase

Stage of dermal healing: Fibroblasts form scar tissue (deeper tissue), characterized by wound contraction and re-epithelialization

Proliferative phase

Stage of dermal healing: Scar Tissue remodeling

Maturation Phase

What are the 6 complications of burns?

1. Infection 2. Shock 3. Pulmonary Complications 4. Metabolic Complications 5. Cardiac and Circulatory complications 6. Integumentary scars and contractures

Leading cause of death of burn patients

Infection (presence of bacteria or microorganism)

Marker for true infection

Presence of bacteria or microorganisms >10/\5/gram of tissue determined by a quantitative culture

What type of shock do burn patients experience?

Hypovolemic Shock

Cause of pulmonary complications in burn patients

Smoke Poisoning

Burns to the trunk will result with what kind of condition?

Restrictive Lung Disease

Increase metabolic rate in burn patients will often result with what physical change?

Increased Weight Loss

Circulatory complications in brun patients include?

fluid and plasma loss leading to decrease in Cardiac Output

True or False Burn patients are prone to develop heterotypic ossification (bone formation in the soft tissue)

True

Most common areas for heterotypic ossification

Elbow Hip Shoulder

Types of Wound Closure: Occurs when a surgeon closes a wound by bringing the edges together

Primary Wound Closure

Types of Wound Closure: Approximating the edges can occur through the use of sutures, staples, glue, skin grafts, or skin flaps.

Primary Wound Closure

Types of Wound Closure: Occurs when a wound is left to heal on its own

Secondary Wound Closure

Types of Wound Closure: The mechanisms of healing are contraction, reepithelialization, or a combination of both.

Secondary Wound Closure

Types of Wound Closure: Wound is allowed to heal by secondary intention

Tertiary Wound Closure

Types of Wound Closure: Then is closed by primary intention as the final treatment

Tertiary Wound Closure

Type of scar: raised scar that stays within the boundaries of the burn

Hypertrophic Scar

Type of Scar: Raised scar extends beyond the boundaries of the original burn wound and is red, raised, firm

Keloid Scar (common in young women, dark skinned)

What is the most common instance for Tertiary Wound Closure?

wound is infection

This type of topical medication is effective against yeast and pseudomonas infections

Silver Sulfadiazide

This type of topical medication is used against gram + and gram - bacteria

Silver Nitrate

This type of topical medication is used for yeast, molds, fungi, viruses and protozoans*

Povidone-Iodine (Betadine)

This type of topical medication is able to penetrates eschars

Mafenide Acetate (Sulfamylon)

This type of topical medication is bactericidal however overuse of it may lead to overgrowth of fungus and pseudomonas infections

Nitrofurazone

Graft that uses the patients own skin

Autograft

graft that uses tissue from a cadaver

Allograft

graft taken from another species (usually pigs)

Xenograft

type of graft where there is combination of collagen and synthetics

Biosynthetic Graft

Lab grown graft from patients own skin.

Cultured Skin

Graft that contains epidermis and papillary layer of the skin

Split thickness graft

Graft that contains epidermis and both layers of the dermis

Full thickness graft

Type of graft used to lengthen graft skin.

Z-plasty

True or False Exercise is d/c to allow healing

True

Common deformity in shoulder joint of burn injuries

Adduction and Internal Rotation

what type of splint is used for shoulder burn patients

Airplane/axillary splint

What is the usual appearance of arterial ulcers?

regular smooth edges with punched out or deep ulcer appearance

What is the usual appearance of venous ulcers?

Irregular edges with dark pigmentation, usually shallow

True or False Venous Ulcers usually occur at the medial malleolus

True (this is the area of maximal venous pressure due to the large perforating vein)

True or False Arterial Ulcers usually occur at the lateral malleolus

True

True or False Gangrene can only occur with arterial and diabetic ulcers

True

What condition will usually present with an ulcer on the plantar aspect of the foot with sensory loss?

Diabetes Milletus (Diabetic Ulcer)

Type of orthosis used to de-load diabetic ulcers

Total Contact and walking boot

Instrument used to check for sensory integrity?

Semmes-weinstein monofilament

How much force does a 4.17mm thin monofilament exert? (semmes-weinstein monofilament)

1 gram of force (normal)

How much force does a 5.07mm thin monofilament exert? (semmes-weinstein monofilament)

10g of force (protective)

How much force does a 6.10mm thin monofilament exert? (semmes-weinstein monofilament)

75g of force (insensate)

Colors of the semmes-weinstein monofilament and indication for each.

Green (normal) Blue (decreased light touch sensation) Purple (decreased protective sensation) Red (loss of protective sensation)

❑Lesion caused by unrelieved pressure resulting in ischemic hypoxia and damage to underlying tissue ❑Usually over bony prominences ❑Common in: elderly, debilitated, or immob individuals, cognitive impairment, decrease sensation

Pressure Ulcer/Decubitus Ulcer

what are the most common sites for pressure ulcers?

Ischium: 28% Sacrum: 17-27% Greater Trochanter: 12-19% Heel: 9-18%

Most common area of Pressure ulcer in Acute SCI patients

Sacrum and Heels

Most common area of Pressure ulcer in Wheelchair Bound patients

Ischial Tuberosity and Feet

Stage of Pressure Ulcer: Non-blanchable ERYTHEMA of intact skin; (+) change in tissue temp, tissue consistency, sensation

Stage 1

Stage of Pressure Ulcer: Partial thickness skin loss; Involves epidermis, dermis or both. Presents as abrasion, blister or SHALLOW CRATER

Stage 2

Stage of Pressure Ulcer: Full thickness skin loss; May extend down to, but not through, underlying fascia. Presents as DEEP CRATER

Stage 3

Stage of Pressure Ulcer: Full thickness skin loss; involves extensive destruction or damage to mm, bone or supporting structures. UNDERMINING and sinus tracts may be present

Stage 4

Stage of Pressure Ulcer: Tissue depth is obscured d/t SLOUGH or eschar and extent of damage cant be determined

Unstageable

Stage of Pressure Ulcer: Discolored area of tissue (bruise) that is not reversible Injury and will likely progress to a full thickness injury

Deep Tissue Injury

Skin looks lighter in color and wrinkly. It may feel soft, wet, or soggy to the touch. Common with sacral ulcers due to too much moisture. (i.e. patients who wear diapers)

Macerated Wound

Linear erosion of skin tissue resulting from mechanical means. Common with sacral ulcers due to too much moisture. (i.e. patients who wear diapers)

Excoriation

Wound with rolled borders

Epibole

Open wound that is extremely dry

Desiccated Wound

Ruptured surgical wound area

Dehiscence

WAGNER ULCER GRADE CLASSIFICATION SCALE: No open lesion but may possess pre-ulcerative lesions; healed ulcers; presence of bony deformity

Grade 0

WAGNER ULCER GRADE CLASSIFICATION SCALE: Superficial ulcer not involving subcutaneous tissue

Grade 1

WAGNER ULCER GRADE CLASSIFICATION SCALE: Deep ulcer with penetration through the subcutaneous; potentially exposing bone, tendon, ligament or joint capsule

Grade 2

WAGNER ULCER GRADE CLASSIFICATION SCALE: Deep ulcer with osteitis, abscess or osteomyelitis

Grade 3

WAGNER ULCER GRADE CLASSIFICATION SCALE: Gangrene of digit

Grade 4

WAGNER ULCER GRADE CLASSIFICATION SCALE: Gangrene of foot requiring disarticulation

Grade 5

Bigger area of tissue destruction than can be seen (extends under the edge).

Undermining

Tracts extending out from the wound.

Tunneling

Wound Drainage: Clear, shiny exudate; can have slightly yellow appearance

Serous

Wound Drainage: Red, blood drainage

Sanguineous

Wound Drainage: Pinkish- red colored exudate

Serosanguineous

Wound Drainage: Brighter yellow drainage, slightly thicker exudate than serous; slightly malodorous

Seropurulent

Wound Drainage: Containing pus; Thick, cloudy or opaque exudate; mal odorous

Purulent

Clean red wound color indicates

Healthy granulation wounds

Yellow wound color indicates

Slough, fibrous tissue

Black wound color indicates

Eschar

Surgical Intervention is used for what stage of ulcers?

Stage 3 and 4

Wound Care: o Patient breathes 100% oxygen in a sealed, full body chamber with an elevated atmospheric pressure o Hyperoxygenation reverses tissue hypoxia and facilitate wound healing o CI: untreated pneumothorax, anti-neoplastic medications

Hyperbaric Oxygen Therapy

o Removal of necrotic or infected tissue that interferes with wound healing o Allows examination of ulcer o Decreases bacterial concentration o Improves wound healing o Decreases spread of infection

Wound Debridement

Delivery System for Wound Debridement: Use of Gauze, cloth, sponge

Minimal mechanical force

Delivery System for Wound Debridement: Use of Syringe, battery-powered irrigation system (pulsatile lavage)

Irrigation: uses 4-15 psi

Delivery System for Wound Debridement: For ulcers with large amount of exudate

Hydrotherapy

METHODS OF DEBRIDEMENT: * Most selective * Used if granulation tissues are greater than necrotic tissues * Uses body's own enzymes and moisture to re- hydrate, soften and finally liquefy hard eschar and slough * CI: immunosuppresed*

Autolytic Debridement

METHODS OF DEBRIDEMENT: * With the use of scalpel, scissors and tweezers * This is contraindicated for patients taking anti-coagulants

Sharp debridement

METHODS OF DEBRIDEMENT: • Use of fibrinolytic and proteolytic enzymes

Enzymatic Debridement 2 types: ``` a) ELASE • Glassy edematous wounds • Venous insufficiency ulcers with fibrous exudates b) TRAVASE • Used for ESCHAR ```

METHODS OF DEBRIDEMENT: * Application of moistened gauze dressing, necrotic tissue will adhere to the gauze * May traumatize healthy or healing tissue

Wet to dry debridement