test 1 Flashcards
4 skin random facts
- largest single organ in the body
- 1/3 of the circulating blood in the body is in the skin
- 20% available protein is used by skin for epidermal replacement
- contains sensory receptors
3 layers of skin and sub layers
1. epidermis: stratums deep -> superficial: germnativum, sinosum, granulosum, ludicum, corneum 2. dermis- str paplare,str reticulare 3. hypodermis
A & P of the edpidermis (5)
- multilayers structure which replaces itself by cell division
- deepest layer is basal cell
- epidermal cells are referred to as keratinocytes
- keratinization is the cells ascending towards the surface
- the skin surface is dead
a&p edpidermis- cell types (3)
keratinocytes- 1. most prevalent 2. considered dead but because of high lipid content form impermeable barrier and keeps water in melanocytes 1. basal cell and give color langerhans cell 1. immune response
dermis (4) 2 layers- composed of 3 things contains... principle purpose
- two layers- papillary layer and reticular layer
- dense irregular, mesodermally derived connective tissue composed of collagen elastin and GCGs
- contains extensive vasculature, nerves, sweat and sebaceous glands, smooth muscles and fibroblasts
- principle mechanical skin barrier
3 types of dermal cells and what they do
- macrophage- phagocytosis
- mast cells- phagocytosis
- release chemicals to attract other cells to area (serotonin) - fibroblasts- lay down new tissues
skin functions (4)
- prevention of loss of essential fluids (stratum corneum)
- thermoregulation because of specialized structures of dermis
- calcium homeostasis and synthesis of vit D
- huge sensory organ
hypodermis (3)
what its made of
purposes
what happens if injured or destroyed
- subcutaneous tissue that is comprised of connective (fascia) and fat tissue
- provides:
insulation, shock absorption, energy storage, keratinocytes - when epidermis is destroyed, lose nourishement** because major blood vessels of skin
wound healing- inflammation days 3-7 (4)
- hemostasis = control of bleeding, vasoconstriction -> dilation
- mast cells release seretonin
- chemotaxis to attract chemicals
- increased platelet activity (to cause clotting) which release of growth factor
3 phases of wound healing and time table
-these are not discrete phases, some overlap
- inflammation- immediate up to 3-7 days
- proliferation= fibroplasia- day 3-21. when wound is closed => maturation
- remodeling = maturation= day 21-2 years
wound healing- proliferation phase 4-24 days (5)
- fibroplasia- laying down fibrin and elastin, profuse blood flow
- granulation- laying down new granulated tissue
- angiogenesis- creating new BV= reestablishing blood flow into the wound
- re-epithelization- migration of epidermal cells on surface of wound
- wound contraction- getting smaller because myofibroblast start to pull edges of wound in
maturation phase/ remodeling (2)
- collagen orientation and lysis
2. increase in tensile strength
per secundam intentionem (3)
- large or infected
- wound contraction and development of granulation tissue from depth and margins of wound
- slow process resulting in scars
per tertiary intentionem (2)
- skin is minimally healed with restored anatomical but not functional continuity
- eg- skin grafts or transplants
4 cardinal signs of inflammation (+1)
- calor (heat)
- rubor (redness)
- dolor (pain)
- tumor (swelling)
- loss of function
per primam intentionem (first intention)(3)
- uncomplicated healing of injury when continuity of tissue is reestablished w/o infection
- small, smooth, approximated wounds
- surgical incision => usually scarless
oscillometry (non-invasive vascular test) (2)
- place cuff around artery where you are concerned with pathology
- inflate cuff for partial occlusion and sensor in cuff can read pulse => get visual representation of strength of pulse
transcutaneous partial O2 pressures (TcPO2) (non-invasive vascular test)
basic (1)
normal and not-normal values (3)
not valid if…(2)
- measures partial pressure of O2 to skin with special machine with sensors on skin (adjacent to wound)
- > 40mmHg = normal
- 30-40mmHg = impaired but can heal
- <30 mm Hg = severely impaired healing- prognosis not as good
- not valid if severe infection or edema
debridement indications (4)
- removal of dead, devitalized, damaged tissue or foreign materials and microorganizms
- helps with infection management (these microorganisms or foreign tissue are breeding grounds for bacteria)
- allow for fibroplasia (proliferation phase of healing can only happen if no dead tissue)
- helps evaluate true wound depth
segmental systolic pressures (non-invasive vascular test (2)
- measuring systolic pressure down leg (thigh, calf, ankle)
2. should decrease as you go down but a change of >20mmHg indicates pathology**
contraindications for sharp debridement (6)
- arterial insufficiency (low ABI)
- blood thinners or asprin
- clotting disorders
- gangrenous tissue (wet gangrene needs surgery,, dry falls off on its own)
- stable heel ulcer
- unidentifiable structures
guidelines for sharp debridement (13)
- all items accessible and sterile
- hand washing and gloving
- optimal positioning for pt and self
- good lighting
- appropriate disposal container
- plan for controlling bleeding
- partial wound cleansing
- wound evaluation
- repeat hand washing and gloving
- conservative approach
- avoid excessive pain and bleeding
- pt and clinician fatigue => multiple short sessions (3-20m)
- integration with other forms of debridement
wound scrubbing (mechanical debridement) (3)
- gentle
- from center to periphery
- instrument called curette which has like a nail file
sharp debridement objective time instruments who can do it? pain management procedure
- objective: only gets rid of dead tissue that is ready to be removed - based on how adherent or painful
- time: only last about 15 min
- instruments: use forceps, scapels
- PT/OT, podiatrists, nurses can all do it
- can be painful so pre-medicate patient
- procedure: cross hatch (score thru tissue) then can remove little squares of necrotic tissue with tweezers or enzyme
ultrasound (mechanical debridement)
what is it good for/ not (2)
frequency measurement
generalities (3)
- good for slough (yellow necrotic tissue) and fibrin
- not effective for eschar (black necrotic tissue)
- kilohertz frequency = sound waves
- direct or indirect contact
- incorporates fine mist
- continuous or pulsed-variable intensity (for pts comfort)
whirlpool agents (mechanical debridement)
3 basics
4 potential contraindications/ precautions
- loosen necrotic tissue
- dressing removal
- neutral to warm temps
potential contraindications/ precautions - cytotoxic agents - need very specific concentrations of things like betadine
- can disrupt growth factors and fibroplasia
- promotes edema (leg in dependent position)
- contraindication for venous stasis wounds because they are susceptible to edema
pulstile lavage (mechanical debridement)
basics/ protocol (2)
what does it stimulate? (2)
precautions (2)
- positive (positive irrigates wound) and negative pressure (removes debris)
- stay below 15 psi
- stimulates angiogenesis and epithelization
- cross contamination
- protective gear for clinicaian
wet to dry dressing (mechanical debridement) (3)
- moistened gauze packed into wound for 8-24 hours and allow to dry then pull out
- not comfortable for pt (and can lead to bleeding)
- non- selective
autolytic debridement (6)
- sealing in wound with *occlusive dressing so bodys own enzymes break down necrotic tissue
- need moist environment (occlusive dressing keeps moisture in)
- cross hatch with scapula for make easier for body to break down
- good adjunct to other forms
- less invasive- painless but takes longer
- protect surrounding tissue (periwound area) from maceration (skin sealant for surrounding tissue so it doesnt get moist)
maggot debridement therapy (7)
details-4
what the maggots are doing
how long -1
contraindications-1- sterilized fly larvae
- moisture donating dressing- usually larvae are emeshed in dressing
- Maggots liquefy and inject necrotic tissue and stimulate fibroblast activity
- leave in 1-3 days
- discomfort but not excessive pain
- fistulas contraindicated
surgical debridement (2)
- > 70% black necrotic tissue should be removed by MD surgeon (under anesthesia)
- in conjunction w/ vascular surgery and grafting
enzymatic debridement what it is who is it good for? can you use if wound is infected? can be used with what other types (2) of debridement?
- enzymes break down dead tissues but not cytotoxic chemicals so doesn’t affect healthy tissue (collagenase is most common used)
- can be costly and irritating but easy to use/ less traumatic for pts who can’t tolerate other types (better for older individuals)
- fine for infected wounds
- use with cross hatching/ moisture
barriers to normal wound healing (5)
plus lots of others
- dehydration
- malnutrition
- infection, poor vascularization
- necrotic tissue/ foreign tissue
- excessive pressure
abnormal wound healing- undermining (2)
what pathology it usually occurs with
what it is
one way to test for it
- occurs with osteomyletis (bone or bone marrow inflammation)
- healing occurs where no basement healing has occured yet (so nothing stable is under the new tissue)
- can stick a probe under wound to feel for complete healing
abnormal wound healing- tunneling (3)
what it is
why is occurs
one way to test for it
- also called fistula- tunnel that goes into other cavity of body
- happens if wound was packed too tight
- can stick a probe under wound to feel for complete healing
abnormal wound healing- epiboly
what it is
why it occurs
- edges of wound roll into base
2. occurs when wound is too dry and edges are looking for moisture
abnormal wound healing- hypergranulation (2)
why it occurs
signs
- occurs because of repetitive trauma or too much moisture
2. causes convexity
abnormal wound healing- hypogranulation (2)
why it occurs
remedy
- poor blood flow
2. cannulation
abnormal wound healing- dehiscence
what it is
4 possible causes
1. when suture line opens up possibly from: 1. too much pressure 2. infection 3. malnutrition 4. radiation
abnormal wound healing- hypertrophic scarring
- overabundance of scar tissue
3 classifications for non-pressure ulcers
- superficial - no depth, just epithelial
- partial thickness- into dermis
- full thickness
classification for pressure ulcers (bed sores)
stage I-stage IV
unstageable
deep tissue injury
stage I - unblanchable
stage II - contained w/i dermis or epidermis
stage III - contained in fascia and adipose
stage IV- down to muscle/tendon/ ligament
(can’t go back in staging, once its a 4 its a 4)
unstageable- necrotic tissue- can’t stage until thats removed
deep tissue ulcer- skin isn’t broken but infection/injury below skin
3 names/ colors of necrotic tissue to document in eval
record % in evaluation
- red- granulation
- yellow- slough - liquid necrotic tissue
- black- eschar- more solid necrotic tissue
types of drainage to document in eval serous sanguineous serosanguinous purulent amounts smell
- serous- clear/ watery
- sanguineous- bloody
- serosanguinous- pinkish = bloody/ watery
- purulent - thick opaque
- amt- none/ scant/ min/ mod/ copious
- smell - none/mild/ strong/ foul/ sweet
chart review: normal blood glucose
70-110mg/dL
pulse- palpation locations (4)
- dorsalis pedis- lat to extensory hallicus and medial to EDL
- posterior tibial artery- behind medial malleoli
- popliteal- femoral triangle
- femoral
pulse grading 0-4
0 - not palpable 1+ - barely perceptible 2+ weak pulse 3+ normal, palpable pulse 4+ abnormally strong pulse
what is stemmers sign?
this is a test for people who have lymphadema.
pick up skin of second toe, if you can’t pick up the skin its a sign of edema.
what is tent sign
pinch skin on dorsum of hand, if dehydrated it will stay elevated
classification/ grading for pitting edema
1-4
push into skin and see how long it stays pushed in for
1 = slight pitting, barely visible
2 = easily identifible but 15 seconds or less
3 = stays pitted 15-30 seconds
4 = stays pitted for >30 seconds
pt evaluation for sensation
usually for DM. use a microfilament and press into dorsum of foot just enough to make it bend- testing protective sensation
braden scale-
what it measures
6 things they are checking
- measure of how at risk for pressure ulcer a pt is
checking for: - sensory perception
- moisture
- activity level (ambulatory?)
- bed mobility (can you change/ control your position)
- nutrition
- friction shear (stand pivot vs. lateral transfer)
interpreting scores on braden scale 15-18 13-14 10-12 </= 9
15-18 low risk of pressure ulcer
13-14 moderate risk
10-12 high risk
</= 9 very high risk
claudication time test (non-invasive vascular test)
- claudication = ischemic pain in peripheral muscle
- walk on treadmill 1 mile/hr until they get pain (usually in calf)
- quantitative = time
- qualitative = level of pain
rubor dependency test (non-invasive vascular [arterial] test)
description of test (2)
normal and abnormal results (2)
- lay pt supine with leg at 60 degrees (or as high as possible) and hold for about 60s, sole of foot should be lighter
- bring foot back down and record how long it takes for color to match other foot
- normal = 15-20 seconds
- abnormal»_space; 20s or hyperemic (exaggerated red) = poor control of vasoconstriction
venous filling test (non-invasive vascular [aterial] test
how to do test
normal and abnormal results
validity
- have pt lay down and elevate foot 60 degrees/ 60 seconds and massage dorsum to push blood out of veins => sitting position and record how long it takes for veins to refil
- 15-20 seconds = normal
- > 20 seconds = abnormal
- not valid if veins refill immediately, indicates venous insufficiency
holmaus sign/ cuff test (2)
- used for blood clots (DVT)
- sitting or supine- extend knee and dorsiflex ankle and squeeze calf - or inflate cuff around calf to 40mm Hg - extreme pain =DVT
doppler sounds (non-invasive vascular test) arterial and venous sounds, and which way to face doppler
- arterial sounds- face tip proximal (to face blood flow)- sounds like heart beat/ bouncy
- venous sounds- face tip distal (to face blood flow)- sounds like wind blowing/ wooshing sounds
ankle brachial index (ABI)
what you measure (2) and normal values
- using doppler, measure systolic p in dorsalis pedis or post tibial artery
- using doppler measure systolic p in brachial artery in both arms and use higher value
- divide dorsalis/ brachial 1.0 = normal (0.9-1.2)
ABI (ankle brachial index) numbers (3) 0.7-0.98 0.5-0.69 <0.5 toe brachial pressure
0.7-0.98 - mild -> moderate arterial occlusion
0.5 - 0.69 - moderate occulsion
<0.5 - severe - can be a predictor for poor wound healing
toe brachial pressure - 0.8-0.9
ABI contraindications and validity (2)
- if ABI 1.2 its not valid
2. can be because diabetics sometimes have calcified arteries
