The Aging Integumentary System Flashcards
________________________ make up 90% of epidermis cells. What do they do?
Keratinocytes, the protein keratin helps waterproof and protect the skin and underlying tissues
The ______ make of 8% of the epidermis, what do they do?
Melanocytes, produce and store the pigment melanin which absorbs UV light
What do Merkel cell do?
Found in epidermis, function in the sensation of touch
What do Langerhans cells do?
Migrate to the epidermis from bone marrow and interact with white blood cells during an immune response
How many layers of the epidermis? Out is called? Inner is called?
Stratum corneum is outer
Stratum basale is inner
5 layers total.
What does the dermis contain?
Blood vessels, elastin, collagen, nerves, macrophages, adipocytes
What does the subcutaneous layer contain?
Adipose tissue, connective tissue, sweat glands, some hair follicles, nerves, lymphatic vessels, and blood vessels
Purple patches/macules are called what?
Actinic purpura, from blood leaking into skin tissue from injury due to loss of hypodermal fat protection.
Cumulative sun damage is called what? Liver spots or age spots from sun are called what?
Dermatoheliosis
Solar lentigo
What on the nails can indicate
1) Zinc deficiency
2) Protein deficiency
3) Anemia
1) White spots
2) Bands across nail
3) Spoon shaped
5 Phases of wound Healing
1) Hemostasis: Platelets, platelet-derived growth factors, inflammatory mediators are found within wound fluids.
2) Inflammation: Leukocytes (particularly neutrophils) destroy bacteria and later macrophages continue to destroy bacteria. Lasts about 4-6 days, longer in older adults, and prolonged inflammation decreases blood flow to area stalling wound healing.)
3) Proliferation: Macrophages, fibroblasts, blood vessels and ground substance make of granulation tissue that is generated during this phase.
4) Epithelialization or late proliferation: keratinocytes migrate from the wound margins, matrix metalloproteinases (MMPs) are also critical in this phase
5) Maturation or remodeling: Collagen fibers are reorganized, by fibroblasts, MMPs, and MMP inhibitors
For cellular proliferation to occur, which 3 key processes need to take place?
Angiogenesis
Fibroblast proliferation
Epithelial proliferation
Involuntary weight loss is defined how?
Loss of 10% of body weight in 6 months or 5% in 30 days.
what is the most common form of malnutrition in aging adults?
Protein energy malnutrition, PEM, wasting and excessive loss of lean body mass, resulting from too little energy being supplied to the body tissue, can be reversed solely by administration of nutrition.
What is the capillary closing pressure?
32 mm Hg
11 types of drugs that contribute to skin alterations
1) Corticosteroids
2) Antibacterials
3) Antihypertensives
4) Analgesics
5) Tricyclics
6) Antihistamines
7) Antineoplastic agents
8) Antipsychotics
9) Diuretics
10) Hypoglycemic agents
11) Disease-modifying antirheumatic drugs
How does hyperglycemia affect the skin?
Decreased collagen synthesis, angiogenesis, fibroblast proliferation, tensile strength, and re-epithelialization
NSAIDs with which disease may have a deleterious effect on wound healing
DM
How do DMARDs affect wound healing?
Decrease polymorphonuclear leukocyte chemotaxis a necessary cellular response in healing
______________ is a condition characterized by the appearance of wheals (raised lesions) that is often associated with food or drug allergic reactions
Urticaria
That stratum corneum requires a moisture content of _____% to remain intact, and a humidity of ______% is required in order to draw moisture from the environment
10%
70%
Excessive washing and bathing strips away surface lipids and induces dryness, referred to as ______
Xerosis
For dermatitis, A lesion less than 1cm is described as a ________ (flat) _______ (raised) _______ (blister.
If greater than 1cm, ________ (flat) _______ (raised) _______ (blister)
Macule, papule, vesicle
Patch, plaque, bulla
Ph of the skin
5.4, higher with atopic eczema
Coin-shaped eczema
Nummular, similar to Asteatotic- similar in that both are seen in individuals with xerosis and cellular immune dysfunction
Latex rubber trees share allergens with which fruits/nuts/veggies
Bananas, chestnuts, kiwis, potatoes, tomatoes, passion fruit
Difference between hypertrophic and keloid scars
Hypertrophic, remain within the wound boundary
Keloid extends beyond
What 5 things increase the risk of skin tears in the aging population?
dehydration, poor nutrition, cognitive impairment, altered mobility, decreased sensation.
______ and _____ dressings have been shown to protects area of skin tear while avoiding further damage
Silicone and foam
The most common complication of shingles, and the 2 most severe complications
Posherpetic neuralgia
Peripheral neuropathy and myelitis
Pyoderma gangrenosum, looks like? Cause?
Enlarged ulcerated plaques that are well demarcated, irregular shaped with elevated purple to deep red edges and boggy necrotic central wound base.
Cause is idiopathic but 50% cases occur in people with systemic diseases like RA
A bacterial load reach of a level of _______ per gram of tissue is seen as a key determinant in infection and delayed wound healing.
> 10^5
Acute vs chronic wound infections
Acute: pain, erythema, swelling, loss of function, increased temp
Chronic: pain, wound breakdown, odor, friable granulation tissue
Superficial bacterial infections NERDS
Deep infections STONES
Non-healing, exudate increasing, red friable granulation, debris on surface, smell
Size increases, temperature of periwound increases, osseous structures can be probed or are exposed, new areas of breakdown, erythema edema and exudate, smell
Marjolin ulcer
Chronic vascular ulcers can degenerate into a malignancy
Actinic Keratosis
Precancerous condition, changes in keratinocytes, can progress to squamous cell carcinoma-single or multiple dry, scaly, adherent lesions..
Dysplastic nevus
Abnormal growth of melanocytes in a mole that can become malignant melanoma
ABCDE method for evaluating a mole
Asymmetry, irregular Border, Color of brown, tan, or black in varying degrees but uniform within the mole, Diameter >6mm, Evolution, enlargement, or elevation of a lesion
Basal cell vs squamous cell carcinoma
Basal: 75% of nonmelanoma carcinoma, found more in light skinned people, arises from hair follicles in the head and neck, appear as lesions with pearly borders, depressed centers, and rolled edges, rarely malignant
Squamous: UV and scars, ulcers, and fistulas can cause it. Affect the skin and mucous membranes, more invasive/malignant, hyperkerototic appearance, may ulcerated, reddish black non-healing wound that has the appearance of caviar.
Among older persons admitted to the hospital for femoral fracture _____% will develop pressure ulcer, with _____% of these occurring by the fifth day of admission.
66%
83%
Stages of pressure ulcers
1) area of intact skin with nonblanchable erythema.
2) Partial thickness wounds, loss of dermis. No bruising, no slough, the presence of bruising suggests suspected deep tissue injury.
3) Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, and muscle not exposed or directly palpable, may be slough
4) Directly palpable or visible bone, tendon, muscle, may have slough or eschar
Unstageable if covered by slough or eschar
Pressure ulcers can develop within ____ to _____ hours of hospital admission
2 to 6
What is the most common cause of leg ulcers?
Chronic venous insufficiency-81% of all cases
8 risk factors for chronic venous insufficiency
1) Maternal family history
2) Obesity
3) Severe trauma to the leg
4) History of deep vein thrombosis
5) DM
6) Chronic heart failure
7) Recent Edema
8) Number of pregnancies
Chronic venous insufficiency ulcers are classically located where?
Above the medial malleolus and on the lower third of the leg, but can also occur near the lateral malleolus and in more severe cases encircle the entire ankle (gaiter area)
How are chronic venous insufficiency ulcers shaped?
Irregular border, usually yellow slough, if debrided dark red granulation tissue
Recommendations for people to reduce edema lower legs due to chronic venous insufficiency
Walk at least once per hour, elevate legs above heart 3 to 4 times per day for at least 30 minutes and at night
What is the Unna boot, who used for?
Impregnated paste bandage, only for modulators people with CVI, also need to assess for arterial venous insufficiency first
Ulcers from PAD are classically located where, and what do they look like
Around the lateral malleolus or tips of toes, beginning as small, round, smooth lesions with a pale pink color and minimal exudate, small blisters may be present. Often quickly turns to black eschar. Skin is often thin, pale, shiny, hair may be absent, coolness increases dismally
A palpable dorsal pedal pulse indicates at least how much pressure?
80 mmHg
The ABI needs to be between which to numbers for adequate blood supply to the legs
.5 to 1.2
How to obtain ABI
Each ankle should be divided by the highest brachial measurement
____ to _____ is considered borderline PAD and requires further evaluation (ABI numbers)
.6 to .8
An A1C value of
7.1%
What and where is a Kennedy Terminal Ulcer?
Usually on sacrum, pear or butterfly shaped, more than 50% die within the next 2-6 weeks, indicates end of life is near
WHO 3 steps for cancer pain management that are used for other pain, i.e. Wound pain as well
1) Use of a non-opioid analgesic with or without a local anesthetic
2) edition of mile opioid, using oral medications as much as possible
3) replacement of mild opioid with a more potent one.
Lipodermatosclerosis
Non-pitting edema
Sclerosis
Pigmentation changes
Indication of venous insufficiency
What does superficial phlebitis look like?
Vein inflammation: bruise-like are of pain that may be warm to the touch over a localized portion of a red, inflamed area.
_____ to ______ gram/kg protein for optimal wound healing
1.0 to 1.5
A serum albumin level of
3.5
2.5
Albumin has a half life of 18-20 days Not an early marker of protein energy malnutrition
Signs of zinc deficiency
Can't be tested in blood Loss of appetite Diarrhea Hair loss Impotence Delayed wound healing Dermatitis/psoriasis Taste abnormalities White spots on nails Mental lethargy/depression
Adverse effects of high level zinc supplementation
affects copper status which can cause anemia because they compete for binding sites
Inhibit healing, impair phagocytosis
General formula for amount of fluids that should be consumed?
1/2 body weight in oz per day
How often should pressure relief occur for prevention of tissue necrosis at pressure points?
5 minutes every hour
Primary vs secondary intention wound closure
Primary: as in surgery, immediately close
Secondary: allow wound to remain open and drain, healing from the base upwards
Standard compression vs support system
Standard compression: Elastic, high pressure at rest, slightly lower with activity
Support: Rigid, inelastic, little pressure at rest but higher pressure with activity
A compression pressure of _____mmHg is recommended for individuals with edema secondary to venous insufficiency
40
Which wound cleansers provide the least injury to keratinocytes and fibroblasts
Saline, Shurclens, SAF-clens
When is autolytic debridement not indicated
Wound with heavy bacterial load or are clinically infected, slow process, doesn’t often work in older people due to perfusion challenges, comorbidities.
TIME acronym for wound bed preparation
Tissue (viable?)
Infection ?
Moisture imbalance
Edge
Which type of wound is most appropriate for NPWT Which 2 issues with a wound make it not appropriate?
Full thickness wounds
Heavy exudate and/or poor granulation tissue
If wound fails to progress after ____ to ____ weeks, using NPWT unit should be reconsidered
2 to 4 weeks
The best results in wound healing have been achieved with which electric current settings, frequency etc
Monophasic, pulsed current, 200 to 800 microcoulombs/sec, 1 hour, 3-5 times per week, results in 2-3 weeks
Rubor of dependency test
Patient sits with feet in dependent position. Clinician notes for increased redness, and if blanches upon elevation sign of PAD
The Trendelenburg test
Test for venous insufficiency, patient in supine, elevate leg to 45 degrees, note any venous distention, then apply tourniquet to distal thigh, and stand patient for 1 minute. The latency to refilling of the superficial veins in the dorsum of the foot is recorded.
Venous distention that occurs within 20 seconds suggests deep perforating vein incompetence, within 10 seconds suggests superficial vein incompetence
Monofilament test
5.07 filament that bends under 10 grams of pressure
10 points tested on the foot: 1, 3, 5 distal phalanges and metatarsal heads, medial and lateral mid foot, heel, and on dorsum of foot between first and second metatarsals
The 2 scales used to assess for risk of pressure ulcers
Norton: 5-20, lower is higher risk
5 factors: physical condition, mental condition, activity, mobility, continence
Braden: 23 points 16 or lower high risk for ulcer
Subscales: Sensory perception, moisture, activity, mobility, nutrition, friction/shear
Wagner diabetic foot ulcer classification
Does not address ischemia or infection 0 preulcerative lesion 1 superficial ulcer 2 deep 3 deep with cellulitis/osteomyelitis/abscess 4 localized gangrene of digit 5 extensive gangrene of whole foot
CEAP for evaluation of chronic venous ulcers
Clinical severity Etiology Anatomy Pathophysiology C0 asymptomatic to C6 presence of active ulcers
