Foundations of Wound and Skin Care Flashcards
(100 cards)
1
Q
Epidermis Cell Types and Function
A
- Kertainocytes: protein keratin filaments, most abundant; at surface
- Langerhans: Monocyte (WBC) turn into Macrophages
- Melanocytes: skin pigment
- Merkel Cell: Mechanosensory receptors for pressure; located on epidermis/dermis interface
2
Q
What layer of the skin do blisters form? Where is this layer located around the body?
A
- Layer: Stratum Lucidum
- Located in Lips, Palms, Soles
3
Q
Epidermal Skin Layers
A
- Straum Cornium: Stratified Outer Layer with flattened cells overlapping
- Stratum Lucidum: Clear/translucent layer that resist shearing
- Stratum granulosum: layer of granules containing a variety lipids, permeability layer between cells
- Strautum Spinosum: layers of keratin, which flatten to form granules
- Stratum basale/germinativum: basal/germinal layer of cells connecting to dermis and pushes cells towards surface forming fingerprints/footprints.
4
Q
Epidermis
A
- Rapid regeneration
- Retains moisture
- Functional barrier
5
Q
Dermis
A
- Cutaneous vasculature
- Nutrition to epidermis
- Matrix for fibroblasts
- Struture support for skin
6
Q
Dermis - Cell Types
A
- Macrophages (eat necrotic tissue)
- Mast cells
- Fibroblasts (make new tissue)
7
Q
Subcutaneous Fucntion
A
- Vascularization to skin/body
- Insulation
8
Q
Subcutaneous Tissue Cell Types
A
- Vascular plexus
- Lymphatics
- Adipose tissue
9
Q
Wound definition
A
An interruption in the continuity of bodily structures
10
Q
Wound Classification - Intention
A
- 1st intention: incised - no tissue loss: epithelization
- 2nd intention: incised - tissue loss: regeneration
- 3rd intention: trauma - structural loss: replacement
11
Q
What are the 3 phases of wound healing?
A
- Phase 1: Inflammatory Phase (1-4 days)
- Phase 2: Proliferative Phase (4 days to 11 months)
- Phase 3: Matrix Formation - Remodeling phase (30 days - 2 years)
12
Q
Phase 1,2 and 3 require what type of interventions?
A
- Phase 1: Debridement and/or cleaning and compression
- Phase 2: ROM to promote circulation
- Phase 3: Stretching tissue
13
Q
As soon as one phase gets to the middle the ____ begins.
A
next phase; therefore there is overlap
14
Q
Cells interact with their environment (extracellular matrix) through cell surface receptor proteins or ____
A
cell adhesion molecules (CAMs)
CAMs are cells that glob to help seal wounds
15
Q
Receptors bind extracellular proteins known as…
A
ligands
16
Q
Cell Biology Initiates signal transduction to upregulate or down regulate ____
A
mRNA (transcription)
17
Q
Cell biology regulated ____ production (translation)
A
protein
18
Q
4 types of ligands:
A
- Cytokines
- Growth Factors
- Hormones
- Chemokines (Chemotaxis = migration)
19
Q
____ can be put into wounds to help spead up the healing process.
A
Growth factors
20
Q
Cardinal Signs
Inflammatory Phase 1
A
Calor: Increased Temp
Dolor: Pain
Rubor: Erythema (Redness)
Tumor: Swelling
Loss of Function
21
Q
An infection =
A
prolonged inflammatory phase
Sign of infection would be an increase in Cardinal Signs
22
Q
Cellular Reaction - Hemostasis
Inflammatoy Phase 1
A
Hagemann Factor XII
* Turns Prothrombin -> Thrombin
* Turns Fibrinogen -> Fibrin
Scab Formation (Eschar)
* Platelets are the first cells to arrive to injury site
* Platelets release Serotonin to create Vasoconstriction
* Platelet produces platelet derived growth factor (PDGF) that forms the Fibrin clot (platelet plug)
* Fibrin clot acts as the protection layer for early repairs (leukocytes, endothelial cells, fibroblasts and smooth muscle cells bind)
* Endothelial cells restructure the fibrin matrix producing Matrix Matalloproteases (MMP’s) and plasmin for fibrinolysis (break down fibrin)
23
Q
Matrix Metalloproteinases (MMPs)
A
- Normal response to healing
- 26 zinc-dependent proteolytix enzymes produced by neutrophils, macrophages, fibroblasts, endothelial cells
- Degrade proteins (collagen and growth factors)
- High levels in chronic wounds, contribute to “biofilm” causing tissue breakdown and chronic inflammation
- Regulated by Tissue Inhibitors of Metalloproteinases (TIMPs) which can be insufficent in chronic wounds
24
Q
Vascular Reaction
Inflammatory Phase 1
A
- Vasocontriction: Platelets release serotonin (Stop Bleeding)
- Vasodialation: Mast Cells release Histamine (Get rid of debre)
- Edema (Transudate and Exudate)
25
Transudate
* Clear
* Ex: Blister Fluid
26
Exudate
* Protein (albumin) and leukocytes (viscous)
* Yellow
27
Cellular Reaction - Phagocytic
* Prerequisite for healing
* Initiated during the first 24-48 hours and lasts up to 2 weeks
* Purpose: Remove foreign bacteria material, damaged cells, dead tissue
PTs do this through debridement
28
Polymorphonuclear leukocytes - Cellular Reaction
* 48 to 72 hours
* Neutrophils: release enzymes for **autolytic debridement**
* Eosinophils: phagocytic; WBC
* Mast Cells: release histamine to create VD and produce chemokines for neutrophil migration to site of injury
29
Autolytic debridement
* Neutrophils do this!
* Funtion: Phagocytosis (Eat debris), lysosome degradation, kill bacteria
30
Mononuclear Leukocytes
* Associated with chronic edema
* Essential to wound healing
* Tolerate hypoxia (low O2)
* **Become macrophages**
* Release chemotactic factors
31
If someone with a long standing wound comes in and it gets biopsied, what on the biopsy would indicate it is still in the inflammatory/acute phase?
* Monocytes!
* Monocytes should change into macrophages; if they don't likely becomes a chronic wound
32
Macrophages
* 72 to 84 hours
* Function in low O2, highly acidotic environment
* Phagocytose (eat) matrix and debris
* Transition between inflammatory phase and proliferative phase
* Secrete cytokines, growth factors (GF) and MMPs
* Angiogenessi GF which stimulates endothelial budding from damaged blood vessels
33
Lymphocytes
* 5-7 days
* Immune System, WBC, defense
* Down regulates excessive inflammation
* Controls prolifration and repair
* Releases cytokines and GFs
* Overlaps inflammatory and proliferative phases.
34
Chemical Mediators
| Inflammatory Phase 1
* Histamine: Vasodialation, increase wall "leakiness"
* Serotonin: Vasoconstriction
* Kinins: Increase small vessel "leakiness"
* Prostaglandins: Increase permeability and attract leukocytes
35
When someone takes anti inflammatory medications, what does it do?
* Prevents chemical mediators from working.
* Leads to poorer wound healing (medications and autoimmunte conditions can slow Wound Healing)
36
Patient presents to hospital with a Concussion and road rash would on there calf. How does this effect wound healing?
* Any type of inflammation in the body such as that caused by a concussion will result in slower wound healing
37
Diseases such as RA, Lupus, Sarcoidosis and AIDS all are affected by....
the inflammatory response due to wound, perpetuating chronic inflammation
38
Complement System has ____ plasma proteins that binds antibodies
* 11
* CS: leukocytes and extra plasma proteins that fight infection
39
Chronic Inflammation
| Inflammatory Phase 1
* Occurs in sealed wounds
* Not characterized by cardinal signs of inflammation
* Adhesions form
* Draining, wet, hasn't progressed, no granulation tissue
Intervention: cut layers away to create acute phase again and provide growth factor moisturizer to help with skin growth
40
Fibroplasia
| Proliferative Phase II
* Myofibroblasts migrate into wound space
* Fibroblasts synthesize (Collagen and Glycosaminoglycans)
41
Angiogensis/Neovascularization/
Vasculogenesis
| Proliferative Phase II
Formation of blood vessels
42
What does collagen synthesis require?
Collagen is the extracellular matrix
Collagen Requires:
* Oxygen (Exercise increases this!)
* Vitamin C
* Amino Acids
* Zinc
* Magnesium
**Smoking delays this process**
43
Why is it important to stretch wounds out?
* Allows for the collagen to lay down nicely and is plyable early
* If you don't move it becomes stuck (nonmovable)
44
What intervention is used to help reorganize hypertrophic scarring?
* Use of pressure!
* Ex: Pressure dressing
45
Re-epithalialization
| Proliferative Phase II
* Begins within hours in superficial wounds
* Epithelial cells line skin appendages
* Epithelial cells begin at wound edges and migrate to the center
* **Contact inhibition stops epithelialization**; Ex: ear percings
46
What 4 things signal that wound repait is needed?
* Electric gradient (charges)
* Pain (stimulates the CNS)
* Infection
-- decreases O2 gradient at wound bed needed for metabolic demand
-- new tissue synthesis
-- collagen remodeling (anaerobic glycolysis)
* Hyperlactate environment (Acidic; Ex: Lactic Acid)
| These send signals for chemotaxis
47
Skin Surface Charge
* -23 mV (Weak electric potential)
* "Skin battery"; driven by Na+ pump
48
Current of Injury - How does it heal?
* Na+ transports the water in epithelium to internal body fluid creating charge potential of **50 mV** across epithelium
* Break in the tissue causes ionic flow through the path of lowest resistance
* **Dry wound bed eliminates the voltage gradient**
49
What cells are involved in charge related healing?
* Galvanotaxis; cells needed for repair are attracted to the poles
* Wound infection recreates/sustains the inflammatory phase
* Mast cells: release histamine, vasodilate, increase cell wall permeability, the release heparin to increase endothelial migration
* Epithelium: receives a signal to migrate from macrophages, neutrophils and current of injury
50
Tissue has a ____ charge
+
51
Skin has a ____ charge
-
52
Removing ____ allows for migration to occur faster
eschar
53
Electrical Stimulation to promote different types of healing
* Autolysis: + on the wound; - on skin
* Infection: - on the wound; + on skin
* Granulation: Alternate everyday
54
Undefined border of redness is a sign of an ____.
infection
55
Wound Contraction
| Pro Phase II
* Myofibroblasts shrink wounds before **or** after epithelialization
* Bring wound edges together at a rate of **0.6-0.7 mm/day**
* Wounds under stress heal faster and more securely
56
Shrinking wounds too much may lead to an ____. To prevent it we put dressings in the space to promote ____.
* abcess
* epithelialization
57
Factors Complicating Wound Healing - intrinsic factors
* foreign material or eschar (contact inhibition)
* immunosuppression
* coagulation disorders
* nutritional deficiencies (Ex: Zinc or protein)
* metabolic diseases, i.e., R.A. or diabetes mellitus
58
Factors Complicating Wound Healing - Environmental
| Tx applied to wound
* “Wound cleansing”
-- Saline/ surfactants vs. cytotoxic agents (acetic acid, hydrogen peroxide, betadine, Dakin's solution)
Good Tx:
* Dressings
* Electrical stimulation (bring edges together)
59
Factors Complicating Wound Healing - Iatrogenic factors
| physical management of wound
* removal of dressings (skin in dressing)
* frequency of wound cleansing
* use of clean or sterile technique
60
Types of abnormal wound repair
* **Hypergranulation** – granulation above the skin level
* **Hypogranulation** – granulation below the skin level
* **Hyperwound contraction with hypogranulation and re-epithelialization** (tunneling); Ex: skin graft put on too soon
61
Wound Assessment
* Compile information form pt Hx, Subjective and Objective Exam
* Determine cause, extent of the wound and any conditions that may delay/complicate wound repair
62
Wound Assessment Subjective
* Pt Hx
* PMH
* Family Hx
* Social Hx
* Current Medications
* Last tetanus shot (within last 10 years)
* Wound Sx w/ activity/rest, elevation, dependency
* Pain
* Parathesia, anesthesia
63
Objective Wound Exam
Assess and Document:
* Location, size & severity
* Dry or draining - note drainage (amount, color, odor) - **Any color is an infection**
* Wound edges
* Surrounding tissue
* Evidence of skin nutrition (skin atrophy/dryness)
* Swelling
* Skin discoloration
64
Wound Measurement Sizing
* Length (Anatomical length from top to bottom
* Width (widest part
* Depth
* Undermining (lift skin and is underneath)
* Tunneling (Entry, **NO Exit**)
* Fistula (Entry and Exit)
65
Wound Classification - Color Schemes
* Black: Necrosis
* Yellow: Slough
* Red: Beefy Red Granulation Tissue
66
Motion Exam
* ROM
* Strength
* General activity/mobility
67
Clinical Signs of Infection vs Inflammation:
Erythema, Fever, Odor
Edema, Drainage, Pain
68
Fluid - you smell a sweet smell and the liquid is green, what does this mean?
* Sweet-psudemonas
* Infected
69
Fluid smells like urine, what does this mean?
* Ammonia (Protease)
* Infected!
70
Serous Fluid
* Clear drainage
* Healthy
71
Serosanguinous
* Pink
72
Sangrious Fluid
* Red
* Likely infected
73
What is performed in a vascular Exam
* Pulses - distal to wound
* Auscultation to detect a briut-caused by:
-- constriction
-- plaque
-- aneurysm
* Doppler
* ABI
74
Causes of Venous Insufficency
* Calf pump failure (don't have musculature)
* Decrease in insteristial fibrinolysis (deposits become hard)
* Harvest vein graft (saphenous for bypass surgery)
* Trauma
75
What does the Trendelenburg test do?
Tests integrity of deep veins (DVTs can form here)
76
What are superficial veins called?
Spider veins
77
What are some tests for venous insufficency?
* Percussion test - detect dilated saphenous vein
* Trendelenburg test
* Cuff test (40 mm Hg)/ Homan’s sign
* Doppler ultrasound
* ABI >1.0
78
Tx - Venous Insufficency
* Cleanse & protect with dressings
* Elevate to decrease edema (Heart level or higher)
* Support with compression wrap
* 40 mmHg
* Ankle pump exercise
* Stop smoking
* Dietary management
79
If someone has a wound why would it be bad to be on a diet?
* They lose out of the oxygen, protein, acetic acid and magnesium in their diet needed for healing
80
What are some ways to help rid edema?
* Elevate feet above heart
* Avoid prolonged sitting or standing
* Ankle pumps
* Schedule frequenct rest breaks
81
Tests for Arterial Insufficiency
* **ABI < 1.0**
* Rubor of dependency
* Venous filling time
* Claudication time
* Foot print measurements
* Sensory testing with monofilament
* **(10 g) 5.07 monofilament**
82
Tx - Arterial Insufficency
* Warm whirlpool (max 98°)
* Dressings to maintain moist environment
* VAC
* Bed rest
* Limit leg elevation & activity
* Limb protection
* Preserve ROM and strength
83
Surgical Tx - Arterial Insufficency
* Arterial reconstruction (bypass artery)
* Endarterectomy (go in and try to open up artery)
* Angioplasty
* Sympathectomy (cut to open things up; Increases blood flow and decreases pain)
* Cold laser
84
Diabetic/Neuropathic Wounds
* **Greater risk with DM > 15 years**
* Greater risk with neuropathy (can’t feel pressure)
* Combination of AI and pressure (Charcot joints)
* Wound healing depends on DM control
* Slows wound healing
* Greater risk of osteomyelitis
* **>1.0 ABI**
85
Why do pressure ulcers occur?
* In Soft Tissue
* Usually over bony prominences
* Results of unrelieved pressure over time
86
Causes/Risk Factors of Pressure Ulcers
* Time/pressure relationship
* **2 hour max in one position**
* **Capillary closing pressure = 32 mm Hg**
* Friction (external rubbing on a surface)
* Shear (stretching of one layer over the other)
* Moisture (Can lead to keratin too wet and masticaiton occurs)
87
Approxmately ____ of decubitis ulcers occur in the pelvic area
75%
88
Pressure Ulcer Tx
* Eliminate cause of pressure by reducing or redistributing
* Use pressure relieving devices (PRD’s)
* Increase activity, maintain ROM & strength
* Local wound care
89
What type of pillow is really good in preventing pressure ulcers?
RIK Fluid Pillow
90
Heel Protection for wounds
* Non-ambulatory
* Ambulatory
91
What are 4 important nutritional requirements for wound healing?
* Protein
* Vitamin C
* Zinc
* Mg
92
Trauma wounds have a higher risk of ____
infection
93
Traumatic Wound Tx
- Protect healthy tissue
-- Wound bed and surrounding tissue
- Wound debridement/cleansing
-- Foreign and necrotic tissue
- Anticipate greater risk of infection
-- Systemic Abx and bactericidal dressing
- Support wound contraction
-- Compression wrapping, VAC, limit joint ROM, ankle pump
94
Silver is a natural ____
antimicrobial
95
Wounds from infection are often ____
* Indurated - tissue swelling, hard to the touch
96
Infection Wound Treatment
- Infection management
-- Systemic antibiotics
-- Reduce bacterial load from wound bed(debride/cleansing)
-- Bactericidal topical dressing
- Pain management
-- Systemic not topical
- Improve circulation
-- systemic and local
- Manage drainage
-- daily dressing changes
-- avoid maceration
97
____ and ____ Trauma will delay healing
* Mechanical and Chemical
* Mechanical Ex: Shear, pressure, ripping off adherent dressings
* Chemical Ex: cleansers and carriers
98
If you can't put it in your eye...
don't put it in your wound
99
What are 4 things to never put in a wound?
* Dakin's solution
* Acetic Acid
* Hydrogen peroxide
* Iodine solutions
**All are toxic to myofibroblasts**
100
Goals of Wound Cleansing/Debridement
* Rid wound of necrotic tissue
* Prevent infection
* Correct abnormal wound repair
