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Clin Path > Week 4 (EXAM 1) > Flashcards

Week 4 (EXAM 1) Flashcards

1
Q

List the stages of wound healing

A

Hemostasis
Phase 1: inflammatory
Phase 2: proliferative
Phase 3: maturation

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2
Q

What happens in hemostasis?

A
  • Vasoconstriction occurs immediately following skin injury to stop any
    bleeding
  • Platelet aggregation occurs as well to stabilize the wound
  • Growth factors are stimulated to begin the healing process
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3
Q

What happens in the inflammation phase?

A
  • Occurs within 24 hours of injury and continues for several days or weeks
    depending on the level of injury
  • Fluid flows from capillaries to interstitial space causing edema: caused by
    enzymes and other cells
  • Vasodilation caused by histamine and leukotrienes
  • This phase involves neutrophils and macrophages which help clean up the
    wound and combat infection
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4
Q

What happens in the proliferation phase?

A
  • Fibroblasts begin to move into area and regenerate the tissue
  • Neovascularization: angiogenesis and granulation tissue is formed
  • Lack of oxygen, decreased pH and increased lactate contribute to new capillary growth
  • Re-epithelialization occurs as the keratinocytes migrate to cover the wound
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5
Q

What happens in the maturation phase?

A
  • After the wound is healed
  • Protein degradation and collagen rearrangement
  • Redness, swelling, itchiness
  • Lasts 6 months to 2 years
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6
Q

What is the difference between acute and chronic wounds?

A
  • Acute wounds are generally uncomplicated, orderly/organized, and rapidly healing.
  • Chronic wounds have a prolonged or lengthy healing process and deviate from expected sequence of repair.
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7
Q

What are some factors that affect wound recovery?

A
  • An infection
  • Too much or too little moisture
  • Debris present (necrotic tissue)
  • Too much heat or cold
  • Another reason (comorbities)
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8
Q

What are some comorbities to consider in wound care?

A
  • Age
  • Mechanical stress to site
  • Behavioral problems (smoking)
  • Circulation problems (arterial/venous)
  • Sensation problems (diabetes or SCI)
  • Lack of nutrition
  • Medications impeding healing
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9
Q

How can aging affect wounds?

A
  • Cellular turnover is decreased
  • Decreased dermal vasculature thus thinner skin
  • Impaired collagen and protein synthesis
  • Decreased calories = decreased collagen synthesis
  • Decreased sweat and oil glands causing dry skin
  • Pain perception decreased
  • Older usually = other comorbities
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10
Q

What are some behavioral problems that can affect wound recovery?

A
  • Alcohol abuse – usually see malnutrition, less likely to seek medical
    attention
  • Smoking – vasoconstriction, increased clot strength, decreased
    oxygen
  • Noncompliance with meds or controlling blood sugar.
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11
Q

What are some etiologies that can cause the wound or make it worse?

A

1) Circulatory problems
2) Decreased sensation
3) Pressure injury
4) burns

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12
Q

How would you classify circulatory disease?

A

Arterial insufficiency (usually distal)
* Decreased blood flow to an area resulting in decreased oxygen
* Ischemia and tissue death
* Amputations

Venous sufficiency (chronic)
* Decreased ability to pump blood out of the extremities
* Edema resulting in wounds from leaking fluid

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13
Q

How would you classify decreased sensation conditions?

A

Diabetes:
* Chronically elevated glucose can lead to neuropathy
* Decreases all phases of wound healing
* Neuropathic wounds

Spinal cord injuries:
* Nerve injury causing loss of sensation below the level of injury
* Pressure ulcers

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14
Q

What should always be avoided in wound care?

A
  • Should not weight bear on a wound if possible
  • Should not perform non weight bearing on unaffected foot of a
    diabetic as this could lead to problems with skin breakdown and
    breakdown of the foot biomechanics
  • May need to think of ways to safely off load the wounded foot but
    keep the patient mobile
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15
Q

What is an example of pressure injuries?

A

Pressure ulcers

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16
Q

List some properties of burn injuries?

A
  • Can result from decreased sensation
  • Accidental/traumatic
  • Scarring
  • Impaired healing after scarring (healed skin is only 80% as strong of original skin)
  • The deeper the burn (3° or greater) the more scarring
  • Scarring: based on genetics and outside forces
  • Age when burned (when younger, body grows but scars don’t. Leads to surgeries and/or deformities)
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17
Q

List the types of burn injuries

A
  • Thermal
  • Chemical
  • Friction
  • Electrical
  • Radiation
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18
Q

What is the pathophysiology of thermal burn injuries?

A
  • 30% of burns have a systemic inflammatory response: (Results in dehydration and hypovolemia which in turn affects oxygen transport and blood flow). escharotomies may be needed
  • Can result in decreased pulmonary function
  • Decreased bacterial killing function
  • Basal metabolic rate increases (burns over 40% can increase RMR 2 times affecting heart, liver, muscles)
  • Burn shock can occur
  • The immune system is compromised as well as the cellular membrane
    transport system thus high risk for infection
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19
Q

What is secreted when there is a burn injury?

A

Secretion of:
* Catecholamine, cortisol, glucagon and dopamine
* These trigger a series of events which lead to the hypermetabolic response
* Net protein loss becomes a problem due to protein metabolism
* Increase glucose production occurs and insulin resistance can occur as well
* Catecholamines and cytokines can cause the insulin resistance

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20
Q

What are the 3 zones of thermal injury?

A
  • Zone of coagulation-irreversible damage of tissues at times of injury
  • Zone of stasis-adjacent to above zone, moderate degree of damage with
    vascular leakage, increased vasoconstrictors, can proceed to necrosis
  • Zone of hyperemia-increased blood supply with healthy tissue
21
Q

What can a burn injury trigger?

A

Burn injury triggers coagulative necrosis of the different layers of skin
as well as underlying tissues

22
Q

What happens in electrical burns?

A

(Ice-berg “deep damage”)

  • High energy current travels through the body
  • The body converts electricity to heat
  • The blood, nerves and vessels have low resistance making the
    current travel easier inside the body thus causing major damage
  • Icer berg affect: minimal skin damage but when opened, maximal tissue
    damage underneath requiring debridement as well as neuropathies due to nerve
    damage
  • Rhabdomyolysis from major muscle damage
  • Voltages > 500-1000 cause deep burns
  • Electricity can cause defibrillation and/or arrhythmias
23
Q

What happens in chemical burns?

A
  • Alcohols, alkalis and acids most common
  • Alcohol causes the least injury with de-epithelialization
  • Acids usually cause tissue coagulation and shrinking of collagen
    tissue fibers
  • The coagulation effect prevents the acid from further penetrating the layers of
    skin
  • Alkalis cause changes in the fat (liquefication necrosis) along with
    shrinking of the collagen tissue fibers allowing further penetration of
    the alkali into deeper tissues
  • Alkalis are worse because the damage is ongoing
  • More rapid and deeper advancement
  • The pH is immediately checked to determine if alkali or acid
  • Irrigation is essential and continued until the pH is neutral then it is
    monitored
  • Acids: HCL, sulfuric acid
  • Alkalis: ammonia, lye (Drano, Liquid Plummer), ammonia
24
Q

What are the types of treatment for wounds?

A

1) Autografting (permanent)
2) Homografting (temporary)
3) Allografting (temporary)

25
Q

Define autografting

A

Split thickness skin graft
Sheet graft
Cultured skin (lab grown, own skin)

  • Harvesting intact
    skin from another
    part of the body and
    placing over wound
  • Permanent
26
Q

Define allografting

A

Fish skin
Pig skin

  • Temporary cover
  • For large burns
  • Allows donor sites to heal for more
    harvesting
  • Fish skin been shown to enhance wound healing as well (anti inflammatory, omega 3 fatty acids, cost effective, structure similarity to human skin)
27
Q

Define homografting

A

Cadaver skin

  • Temporary cover
  • For large burns
  • Allows donor sites to heal for more harvesting
28
Q

What are the scarring types?

A

Hypertrophic scarring
* Raised and rigid
* Hyper pigmented
* Can limit range of motion
* Darker skin types more likely to scar

Keloid
* Excessive growth of scar tissue
* Hard, benign growths
* Darker skin types more likely to scar

29
Q

What is the standard of care for burn treatments?

A
  • Begin positioning quickly using splints or pillows
  • Begin range of motion quickly: easier to prevent than to correct
  • Immobilization due to grafting: typically, 4-6 days on hold after auto
    grafting depending on where and MD
  • Strength training quickly due to high metabolism and loss of muscle
    mass
  • Know where exposed tendons are located and take care to minimize
    forces during range of motion
  • Older you are and higher percent=lower life expectancy
  • closer they add up to 140, increased likelihood of death
  • Get patients up quickly and walk (early mobility)
30
Q

What are the contraindications to exercise/ambulation when there is a wound?

A
  • Wound on foot, NWB should be the tried, if not then use of an
    assistive device to decrease weight bearing
  • Special shoes to off load area of wound
  • Wound on Achilles tendon and it is exposed, no forceful range of
    motion as this could tear or snap the tendon
  • Heterotrophic ossification: no passive motion, pain is their guide
    (mostly in burn patients)
31
Q

What are the goals for general wound care?

A
  • Debridement: remove the obstacle (nonviable tissue) that may be
    delaying healing and increase potential for infection
  • Cleaning: to prevent infection of wounds
  • Modalities to improve circulation
  • Modalities/topicals to prevent/treat infection
  • Protection: various dressings available to protect against infection and
    facilitate healing
32
Q

What is pulsed lavage?

A
  • Delivery of a liquid agent such as saline under pressure by a device
  • Has concurrent suction
  • Applies a negative pressure during the suction aspect
  • Irrigates at a pressure of 5-15 PSI which breaks up the bonds that
    hold bacteria to the wound bed
33
Q

Describe E-stim for wound care

A
  • Use of capacitive coupled electrical current to transfer energy to
    wound
  • One rationale: mimics the natural current of injury and will jump-start
    or accelerate wound healing
  • Only electrotherapeutic modality or physical agent suggested by
    Clinical Practice Guidelines for the Treatment of Pressure Ulcers
  • Improve blood flow
  • Treat infected wounds
34
Q

Describe mist therapy for wound care

A
  • 40 kHz
  • Uses atomized mist of sterile saline
  • Claims decreased bacterial levels, decreased microbe growth, improvement of
    antibiotic function, and disruption and removal of bacterial bioburden
35
Q

Describe oxygen therapy for wound care

A

Studies indicate that most occurrences for non-healing wounds is
secondary to tissue hypoxia
* Increased edema
* Increased ischemia
* Increased infection

36
Q

Describe negative pressure for wound therapy

A
  • Negative pressure wound therapy
  • Sub atmospheric pressure/suction, to wound bed
  • Suction effect removes excess fluid allowing for enhanced circulation
    and disposal of cellular waste.
37
Q

What is debridement and what are the tools often used

A

Removal of dead tissue to decrease potential for infection and allow
for healing
* Scalpel
* Forceps
* Scissors
* Curette
* Maggots

38
Q

Describe maggot therapy

A
  • Biosurgery
  • Larvae selectively ingest necrotic tissue and excrete proteolytic
    enzymes
  • Thought to be antimicrobial as the larvae secrete ammonia which
    raises the wound pH
  • Larva also ingest the bacteria present in the wound
39
Q

What are the degrees of burns?

A

1st degree: (superficial thickness), painful, does not scar or blister

2nd degree: (superficial partial or intermediate), most painful, blisters, scars

3rd degree: (full thickness), dry, less sensitive, high risk of infection

4th degree: involves muscle or bone, loss of burned part

40
Q

Describe hyper metabolism in burn injury

A

1) burn injury
2) multiple systems affected
3) hyperglycemia and hyperlipidemia
4) whole body catabolism
5) organ dysfunction, sepsis, death

41
Q

Describe SIRS/Sepsis from a burn injury

A

1) burn injury
2) DAMPs and PAMPs released
3) hypovolemic shock and vascular leak, immune and inflammatory response, hypermetabolism, immunosuppression, bacterial multiplication
4) SIRS and/or Sepsis
5) multiple organ failure
6) death

42
Q

Explain starling’s forces during severe burns

A
  1. Increased Capillary Permeability: A burn injury causes inflammation, leading to the release of inflammatory mediators such as histamine. These mediators increase capillary permeability, allowing proteins and fluids to leak out of the capillaries into the interstitial space.
    1. Increased Capillary Hydrostatic Pressure: Due to the inflammatory response, the blood flow to the affected area increases, raising the capillary hydrostatic pressure. This pressure pushes more fluid out of the capillaries into the interstitial space, contributing to edema.
    2. Decreased Plasma Oncotic Pressure: As proteins leak out of the capillaries due to increased permeability, the oncotic pressure (the pressure that normally pulls fluid back into the capillaries) decreases. This reduction means less fluid is reabsorbed back into the capillaries, worsening the fluid accumulation in the tissues.
    3. Increased Interstitial Oncotic Pressure: The proteins that escape the capillaries increase the oncotic pressure in the interstitial space, further pulling more fluid out of the capillaries.
43
Q

What do the inflammatory mediator’s effects on endothelial & smooth muscle cells result in?

A

result in leakage of fluid from the intravascular to extravascular space at the site of the burned tissue, and systemically in all organs leading to hypovolemic shock.

44
Q

Can Resuscitation causes edema?

A

Yes, it can contribute to morbidity and mortality in the thermally injured patient

45
Q

What other factors can contribute to inflammatory response, hypotension, and poor organ perfusion?

A

1) Reactive oxygen species produced by injured tissue contributes to the inflammatory response.
2) Nitric oxide production after injury potentiates endothelial leak, contributing to hypotension and poor organ perfusion.

46
Q

Does the body breakdown muscle when recovery from severe burns?

A

Yes, for the amino acids

47
Q

Does the muscles of a severely burned patient return to full strength?

A

No, even if the muscle size returns to normal. The torque is still less

48
Q

What are the implications of severe burns for PT/OT?

A

1) Pts with severe burns are immobilized with splints and casts to allow wound healing.
2) Begin with PROM to maintain joint motion and prevent contracture
3) AROM and functional activities begin when appropriate to preserve strength and function

49
Q

Even though Severe burn injury results in reduced cardiorespiratory capacity and muscle strength and endurance. Should the pt still exercise early on?

A

Yes.
Proper nutrition is the 1st aspect to approach. However, Aerobic and strength rehabilitative exercises improve cardiorespiratory and muscle functions over standard of care alone (no exercise)

(The metabolic rate goes high during the exercise, but after it becomes lower than what it was prior to exercising “approaching normal levels”)

Clin Path (12 decks)

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