Integumentary

Question 1

Indolent =

Answer 1

a long-standing, often painless wound that is very slow to heal and is a characteristic of a venous insufficiency ulcer

Question 2

induration=

Answer 2

the hardening of the skin around an ulcer, often occurring with pressure sores or venous insufficiency ulcers

Question 3

maceration=

Answer 3

the softening and deterioration of the skin or wound as a result of moisture

Question 4

purulent=

Answer 4

indicates a wound that contains pus and is infected

Question 5

Functions of the skin

Answer 5

1- protect underlying body structures against injury or invasion

2-insulation of body

3- maintenance of homeostasis: fluid balance, regulation of body temp

4- assists in metabolism:

• vitamin D production
• aids in elimination of metabolic waste (era and salt are excreted in sweat)

5- attachment of muscles (erector pili, frontalis)

6- receptors in dermis give rise to cutaneous sensations

Question 6

layers of the skin

Answer 6

Epidermis: outer layer
-no bood vessels

Dermis: inner layer

• composed primarily of collagen and elastin fibrous CT
• contains blood vessels, lymphatics, nerve endings, sebaceous and sweat glands

Subcutaneous tissues (hypodermis): underneath dermis

• “superficial fascia or subcutaneous fat”
• consists of loose connective and fat tissues
• provides insulation, support, and cushion for skin; stores energy
• muscles and deep fascia lie underneath subcutaneous layer

Question 7

appendages of the skin

Answer 7

Hair

• terminal hair
• vellus hair

Nails

Sebaceous glands

Sweat glands

Question 8

sebaceous glands

Answer 8

exocrine glands that secrete fatty substance (sebum) through hair follicles

found on all skin surfaces except palms and soles

sebum lubricates skin, defends against bacteria and fungus

Question 9

sweat glands

Answer 9

Eccrine glands:

• widely distributed, open on skin
• help control body temp

Apocrine glands:

• found in axillary and genital areas
• open into hair follicles
• stimulated by emotional stress

Question 10

Dermatitis

Answer 10

“eczema”

inflammation; causes itching, redness, skin lesions

Causes:

• allergic or contact dermatitis (poison ivy, harsh soaps, chemicals, adhesive tapes)
• Actinic: photosensitivity, reaction to sunlight, UV
• Atopic: unknown, associated with allergic, hereditary or psychological disorders

Stages:

• Acute: red, oozing, crusting rash; extensive erosions, exudate, pruritic vesicles
• Subacute: erythematous skin, scaling, scattered plaques
• Chronic: thickened skin, increased skin marking secondary to scratching; fibrotic papillose, and nodules; post inflammatory pigmentation changes. Course can be relapsing

Precautions:

• some modalities
• avoid alcohol

Medical mgmt:
-topical or systemic therapy (corticosteroids, immunosuppressants, antihistamines)

Question 11

Bacterial infections

Answer 11

enter through portals in the skin (abrasions or puncture wounds)

1- impetigo
2-cellulitis
3-abscess

Question 12

Impetigo

Answer 12

superficial bacterial skin infection caused by staphylococci or streptococci

associated with inflammation, small pus filled vesicles, itching

contagious; common in children and elderly

Question 13

Cellulitis

Answer 13

suppurative inflammation of cellular or CT in or close to the skin

tends to be poorly defined and widespread

streptococcal or staphylococcal infection common; can be contagious

skin is hot, red and edematous

management:
- antibiotics
- elevation
- cool, wet dressings

if untreated: lymphangitis, gangrene, abscess and sepsis can occur

increased risk: elderly, diabetes, wounds, malnutrition, or on steroid therapy

Question 14

Abscess

Answer 14

a cavity containing pus and surrounded by inflamed tissue

result of a localized infection

commonly a staphylococcal infection

healing typically facilitated by draining or incising the abscess

Question 15

List of Vial infections

Answer 15

Herpes 1 (simplex)
Herpes 2
Herpes zoster (shingles)
Warts

Question 16

Herpes 1

Answer 16

herpes simplex

itching and soreness, followed by vesicular eruption of the skin on the face or mouth

a cold sore or fever blister

Question 17

Herpes 2

Answer 17

common cause of vesicular genital eruption

spread by sexual contact

in newborns may cause meningoencephalitis; may be fatal

Question 18

Herpes zoster

Answer 18

“shingles”

caused by varicella-zoster (chickenpox); reactivation of virus lying dormant in cerebral ganglia or ganglia of posterior nerve roots

pain and tingling affecting spinal or cranial nerve dermatome

• progresses to red papules along distribution of infected nerve
• red papillose progress to vesicles develop along a dermatome

accompanied by fever, chills, malaise, GI disturbances

ocular complications with CN III: eye pain, corneal damage
loss of vision with CN V

Management: no curative agent

• antiviral drugs slow progression
• symptomatic tx for itching and pain (systemic corticosteroids

contagious to those who haven’t have chickenpox

**heat/US contraindicated: can increase severity

Question 19

warts

Answer 19

common, benign infection by HPVs

transmission through direct contact

Question 20

Fungal infections

Answer 20

Ringworm (tinea corporis)

• fungal infection of hair, skin, nails
• forms ring shaped patches with vesicles or scales
• itchy; through direct contact
• treated with topical or oral anti fungal drugs

Athlete’s foot

• fungal infection of foot, typically b/w toes
• causes erythema, inflammation, pruritus, itching, and pain
• treated with anti fungal creams
• can progress to bacterial infections, cellulitis if untreated

transmission: person-person or animal to person
- standard precautions

Question 21

Parasitic infections

Answer 21

caused by insect and animal contacts

transmission: person to person or sex
- standard precautions

1- Scabies (mites)

• burrow into skin, causing inflammation, itching, and possibly pruritus
• treated with scabicide

2- Lice (pediculosis)

• parasite that can affect head, body, genitals, with bite marks, redness and nits
• tx: special soap/shampoo

Question 22

List of Immune disorders of the skin

Answer 22

1- psoriasis

2-lupus erythematosus

3-scleroderma

4-polymyositis (PM)

Question 23

psorasis

Answer 23

chronic autoimmune disease of skin characterized by erythematous plaques covered with a silvery scale
-common on ears, scalp, knees, elbows and genitalia

S&S: itching and pain from dry, cracked lesions

variable course

may be associated with psoriatic arthritis, joint pain, particularly in small joints

etiology: hereditary, associated immune disorders, certain drugs

precipitating factors:

• trauma
• infection
• pregnancy and endocrine changes
• cold weather
• smoking
• anxiety/stress

mgmt: no cure
- corticosteroids
- occlusive oitnments
- immunosuppressive drugs: methotrexate

PT:
long wave UV light
-combo UV light with oral photosensitizing drugs (psoralen)

Question 24

lupus erythematosus

Answer 24

chronic, progressive autoimmune inflammatory disorder of CT
-characteristic red rash with raised, red, scaly plaques

Discoid lupus (DLE): affects only skin

• flare ups with sun exposure
• lesions can resolve or cause atrophy, permanent scarring, hypo or hyper pigmentation

Systemic lupus (SLE): chronic, systemic inflammatory disorder affecting pultiple organ systems, including skin, joints, kidneys, heart, NS, mucous membranes

• can be fatal
• common in young women
• Symptoms: fever, malaise, butterfly rash across bridge of nose, skin lesions, chronic fatigue, arthralgia, arthritis, skin rashes, photosensitivity, anemia, hair loss, Raynauds

management: no cure
- topical tx of skin lesions (corticosteroids)

• observe for side effects of corticosteroids
• edema, weight gain, acne, HTN, bruising, purplish stretch marks
• long term associated with increased susceptibility to infection (immunosuppressed), osteoporosis, myopathy, tendon rupture, diabetes, gastric irritation, low potassium

Question 25

long term risks with corticosteroids

Answer 25

``` immunosuppression osteoporosis myopathy tendon rupture diabetes gastric irritation low potassium ```

Question 26

scleroderma

Answer 26

chronic, autoimmune diffuse disease of CT causing fibrosis of skin, joints, blood vessels and internal organs (GI tracts, lungs, heart, kidneys) -usually accompanied with Raynauds skin is taut, firm, edematous, firmly bound to subcutaneous tissues limited systemic sclerosis/sclerderma: - symmetrical skin involvement of distal extremities and face - slow progression of skin changes - late visceral and pulmonary HTN involvement - associated with CREST syndrome Diffuse systemic sclerosis disease/scleroderma: - symmetrical widespread skin involvement of distal and primal extremities, face, trunk - rapid progression of skin changes with early appearance of visceral involvement - important internal organs frequently involved: kidneys, heart and lungs Mgmt: no specific therapy -corticosteroids, vasodilators, analgesics, immunosuppressive PT: slow down development of contracture and deformity Precautions with sclerosed skin: - sensitive to pressure - acute HTN may occur - stress regular BP checks and VC monitoring - pulmonary HTN can lead to R sided heart failure in severe cases

Question 27

CREST syndrome

Answer 27

``` Calcinosis Raynaud's Esophageal dysfunction Sclerodactyly Telangiectasias ```

Question 28

polymyositis

Answer 28

a disease of CT characterized by edema, inflammation and degeneration of the muscles -dermatitis with some forms affects primarily proximal muscles: shoulder and pelvic girdle, neck, pharynx; symmetrical distribution etiology: unknown; autoimmune reaction affecting muscle tissue with degeneration and regeneration, fiber atrophy; inflammatory infiltrates rapid, severe onset: may require ventilatory assistance, tube feeding cardiac involvement; may be fatal mgmt: corticosteroids and immunosuppressants precautions: - additional muscle fiber damage with too much exercise - contractures and pressure ulcers from inactivity PT: - fatigue mgmt, conservation of energy - exercise (aerobic and resistance exercise at low levels) - positioning to prevent contractures and ulcers

Question 29

benign skin tumors

Answer 29

seborrheic keratosis -removed with cryotherapy actinic keratosis: flat, round, irregular -precancerous- can lead to squamous cell carcinoma common mole/benign nevus -proliferation of melanocytes

Question 30

Malignant skin tumors

Answer 30

basal cell carcinoma squamous cell carcinoma malignant melanoma kaposi's sarcoma

Question 31

basal cell carcinoma

Answer 31

slow growing, epithelial basal cell tumor characterized by raised patch with ivory appearance or as a reddened area of eczema rolled border with indented center or presents as a thickened area of skin rarely metastasizes, common on face in fair skinned associated mostly with prolonged sun exposure

Question 32

squamous cell carcinoma

Answer 32

poor defined margins presents as a flat, red area, ulcer or nodule grows more quickly, common on sun exposed areas, face and neck, back of hand higher risk to metastasize

Question 33

malignant melanoma

Answer 33

tumor arising from melanocytes ``` clinical manifestations: ABCDEs -Asymmetry -Border -Color -Diameter >6mm Elevation/Evolution ```

Question 34

contusion

Answer 34

"bruise" skin is not broken pain, swelling, discoloration immediate cold pack can limit effects

Question 35

eccymosis

Answer 35

bluish discoloration of skin caused by extravasation of blood into the subcutaneous tissues result of trauma to underlying blood vessels or fragile vessel walls

Question 36

petechiae

Answer 36

tiny red/purple hemorrhagic spots on the skin

Question 37

abrasion

Answer 37

scraping away of skin

Question 38

laceration

Answer 38

an irregular tear of the skin | torn, jagged wound

Question 39

pruritus

Answer 39

itching common in diabetes, drug hypersensitivity, hyperthyroidism

Question 40

turgur

Answer 40

lift skin on back of hands | indicates hydration status sss

Question 41

examination of skin

Answer 41

``` pruritis uticaria rash xeroderma edema changes in nails changes in skin changes in skin color changes in skin temp hidrosis changes in hair presence of lesions, unusual growths ```

Question 42

uticaria

Answer 42

smooth, red, elevated patches of skin "hives" indicative of an allergic response to drugs or infection

Question 43

xeroderma

Answer 43

excessive dryness of skin with shedding of epithelium can indicate deficiency of thyroid function, diabetes

Question 44

edema can indicate:

Answer 44

can indicate anemia, venous or lymphatic obstruction, inflammation; cardiac, circulatory or renal decompensation determine activities/postures that aggravate or relieve palpation, volume and girth measures

Question 45

change in nails

Answer 45

clubbing: thickened and rounded nail end with spongy proximal fold - indicates Crohn's or cardiac/cyanosis, lung (cancer, chronic hypoxia), ulcerative colitis, biliary cirrhosis, neoplasm, GI involvement - Schamroth's window test- loss of diamond space white spots seen with trauma to nails splinter hemorrhages: small areas of bleeding under nail bets -possible cardiac or renal signs

Question 46

changes in skin color

Answer 46

cherry red: palmar erythema could indicate liver or renal issues cyanosis: slightly blue/gray - indicates lack of oxygen-- CHF, advanced lung disease, congenital heart disease, venous obstruction pallor- pale - indicate anemia, internal hemorrhage, lack of sun - temporary pallor seen with arterial insufficiency and syncope, chills, shock, vasomotor instability or nervousness yellow/jaundice: liver disease liver spots: brown/yellow spots may be due to aging, uterine and liver malignancies, pregnancy brown: pigmentation or venous insufficiency (hemosiderinosis)

Question 47

changes in skin temperature

Answer 47

abnormal heat: - febrile condition - hyperthyroidism - mental excitement - excessive salt intake abnormal cold: -poor circulation or obstruction (vasomotor spasm, thrombosis, hypothyroidism)

Question 48

hidrosis

Answer 48

hyperhydrosis (moist skin)- increased perspiration - fevers - pneomonic crisis - drugs, hot drinks, exercise hypohydrosis- dry skin - dehydration - ichthyosis - hypothyroidism - seen in late DM cold sweats - fear, anxiety, depression - AIDS

Question 49

Burn wound zones

Answer 49

zone of hyperemia: -minimal cell injury; cells should recover zone of stasis: - cells are injured - may die without specialized treatment usually within 24-48 hours zone of coagulation: - cells are irreversibly injured - cell death occurs

Question 50

Burn would classification

Answer 50

1st degree: Epidermal burn 2nd degree: - superficial partial thickness - deep partial thickness 3rd degree: full thickness 4th degree: subdermal burn Classification by percentage of body area burned: - Critical: 10% 3rd degree and >30% 2nd deg; complications common - Moderate:

Question 51

1st degree burn

Answer 51

"epidermal burn" Characteristics: - damage to epidermis only - pink/red appearance - no blistering; dry surface - tenderness, delayed pain Healing/scarring - spontaneous healing in 3-7 days - no scarring

Question 52

2nd degree burn: superficial partial thickness burn

Answer 52

Characteristics: - epidermis and upper layers of dermis damaged - bright pink/red appearance - blanching with brisk capillary refill - blisters, moist surface, weeping - moderate edema - painful, sensitive to touch, temp changes Healing/scarring: - spontaneous healing; typically 7-21 days - min or no scarring; discoloration

Question 53

2nd degree burn: deep partial thickness burn

Answer 53

Characteristics: - severe damage to epidermis and dermis with injury to nerve endings, hair follicles and sweat glands - mixed red or waxy white appearance - blanching with slow capillary refill - broken blisters, wet surface - marked edema - sensitive to pressure but insensitive to light touch or soft pin prick (not all nerve endings are destroyed Healing/scarring -slow healing and occurs through scar formation and reepithelialization -excessive scarring w/out preventative tx 3-5 weeks

Question 54

3rd degree:

Answer 54

"full thickness burns" Characteristics: - complete destruction of epidermis, dermis and subcutaneous tissues; may extend into muscle - white (ischemic), charred, tan or black appearance - no blanching; poor distal circulation - parchment-like, dry leathery surface; depressed area - little pain; nerve endings destroyed (severe pain in surrounding tissues) Healing/scarring - removal of eschar and skin grafting are necessary due to destruction of dermal and epidermal tissue - risk of infection increased - hypertrophic scarring and wound contracture are likely to develop without preventative measures - keloid scarring (scar beyond boundaries of original burn can occur)

Question 55

4th degree burn

Answer 55

subcutaneous burn Characteristics: - complete destruction of epidermis, dermis, with involvement of subcutaneous tissues and muscle - charred appearance - destruction of vascular system, may lead to additional necrosis - from electrical burns; prolonged contact with flame - additional complications likely with electrical burns: ventricular fibrillation, acute kidney damage, SC damage Healing/scarring: - heals with skin grafting and scarring - requires extensive surgery; amputation may be necessary

Question 56

complications of burn injuries

Answer 56

infection: leading cause of death; gangrene may develop - the destruction of defense mechanisms against bacteria shock pulmonary complications - smoke inhalation -->pulmonary edema and airway obstruction - restrictive lung disease from trunk burns - death due to pneumonia metabolic complications -increased metabolic and catabolic activity results in weight loss, negative nitrogen balance and decreased energy cardiac and circulatory complications: -fluid and plasma loss results in decreased CO integumentary scars and contractures

Question 57

epithelial healing:

Answer 57

retention of viable cells allows for epithelialization to occur -cells grow, proliferate and migrate to cover the wound PT should be concerned with protecting and moisturizing the epithelial cells to promote wound healing -loss of sebaceous glands

Question 58

dermal healing

Answer 58

results in scar formation (injured tissue is replaced by CT) scars are initially red or purple, later white

Question 59

healing phases

Answer 59

1- inflammation phase: - redness, edema, warmth, pain, decreased ROM - 3-5 days 2- Proliferation phase - granulation or fibroblastic phase - 4 primary events: angiogenesis, granulaton formation, wound contraction, epithelialization - begins 2-3 days after and lasts several weeks - characterized by wound contracture, granulation tissue filling the defect and epithelial cells migrating from the wound margins 3- Maturation phase: - begins 2-4 weeks after injury, remodeling lasts up to 2 years - normal mature scar is soft, white and flat - 6-12 weeks scar is immature (bright pink) - scarring- hypertrophic, keloid, hypotrophic

Question 60

Hypertrophic scarring

Answer 60

raised scar that stays within the boundaries of the burn wound is characteristically red, raised, firm collagen production rate exceeds breakdown

Question 61

Keloid scarring

Answer 61

raised scar that extends beyond the boundaries of the original burn wound and is red, raised firm -more common in young women and those with dark skin collagen production exceeds breakdown

Question 62

Hypotrophic scarring

Answer 62

flat and depressed below the surrounding skin

Question 63

Burn management:

Answer 63

emergency: - immersion in cold water - cover with sterile bandage, no ointments/creams ``` Medical management: 1:asepsis and wound care -remove charred clothing -wound cleanse -topical meds (antibacterials) -dressings 2- maintain respiratory funciton 3- monitor ABG, VS, GI function 4- pian relief 5- prevention/control infection 6- fluid replacement therapy 7- surgery ```

Question 64

topical meds for burns

Answer 64

ointments: - bacitracin - polymyxin B - neomyxin Silver sulfadiazine sulfamylon- penetrates through eschar

Question 65

dressings for burns

Answer 65

``` Functions: prevent bacterial contamination prevent fluid loss protect wound may additionally limit ROM ``` ``` Dressings: silver impregnated hydrogels petroleum-impregnated gauze ```

Question 66

debridement

Answer 66

used to remove necrotic tissue, prevent infection and promote revascularization and/or reepithelialization selective: scalpel, autolytic dressings, etc non-selective: hydrotherapy and dressings (wet-wet, wet-dry, dry-dry) in which necrotic tissue clings to the dressing when removed

Question 67

burn surgery

Answer 67

primary reason: removal of eschar - early excision is easier on patient - promotes more rapid healing - reduces infection and scarring - more economical than repeated debridement - prevents tourniquet effects

Question 68

Skin grafts types?

Answer 68

used to close a burn wound at the time of primary excision Autograft: made from patient's own skin Allograft/homograft: skin taken from a cadaver Xenograft/heterograft: skin from another species (usually pig) Split thickness: epidermis and upper layers of dermis from donor Full thickness: both epidermis and dermis from donor **discontinue exercise for 3-5 days to allow grafts to heal

Question 69

compression therapy for burns

Answer 69

following grafting, the injured part is rested and pressure dressings are applied to reduce graft separation pressure garments (custom) are used to help prevent or minimize hypertrophic or keloid scarring

Question 70

PT for burns

Answer 70

prevent scar contracture **AROM 2 hrs w/in 24 hours of admission -->PROM maintain ROM maintain/improve muscular strength maintain/improve endurance return to normal function and ADLs immersion in hydrotherapy tank -contraindicated with severe cardiovascular, renal or pulmonary restrictions debridement -autolytic dressings help remove eschar exercises to promote deep breathing and chest expansion ambulation to prevent pneumonia edema control massage to reduce scar formation- deep friction

Question 71

Splinting and positioning burn wounds

Answer 71

1: Anterior neck: flexion contracture - position hyperextsion with a firm cervical brace 2-Shoulder: adduction and IR contracture -position ABD and ER using airplane splint 3- Elbow: flexion and pronation contracture -position in extension and supination splint 4- Hand: - claw hand contracture: position in wrist ext, MCP flexion, IP extension brace - flexion & ADD contracture: extension & ABD brace 5- Knee: flexion contracture -position in extension, posterior knee splint 6- Ankle: PF contracture -position in DF or neutral in AFO

Question 72

Venous ulcers

Answer 72

Etiology: - venous insufficiency - valvular incompetence - DVT - venous HTN - calf muscle pump failure - varicose veins S&S: - can occur anywhere in lower leg; common over medial malleolus - normal pulse - pain: none to min in dependent position - normal color or cyanotic in dependent posiiton - --hemisiderosis dark pigmentation - --liposclerosis- thick, tender, fibrosed - normal temp - edema: present, often marked - ulceration: wet with large amount of exudate Treatment: - elevation and compression to control edema is vital (Unna boot, stockings, intermittent compression therapy) - whirlpool NOT helpful d/t dependent position - active exercise - stockings long term **ABI contraindicated if

Question 73

Arterial ulcers

Answer 73

Etiology: - chronic arterial insufficiency - arteriosclerosis obliterans - arthroembolism - diabetes S&S - occurs in lower leg; typically lateral malleolus, shin and small toes - decreased/absent pulse - preceeded by intermittent claudication - pain: often severe, intermittent, exacerbated with limb elevation - color: pale with elevation, + rubor of dependency - temp: cool - skin changes: trophic changes (thin, shiny, atrophic skin); loss of hair on foot and toes; thickened nails - ulceration: of toes or feet, can be deep - gangrene: black, gangrenous skin adjacent to ulcer can develop TX: - bed rest, HOB elevated - stop smoking - wound care - ROM - wound VAC - if ABI

Question 74

diabetic ulcer

Answer 74

diabetes associated with arterial disease and peripheral neuropathy -caused by repetitive trauma on insensitive skin S&S: - occurs where arterial ulcers occur or where peripheral neuropathy occurs (plantar foot - pain: typically not painful d/t sensory loss - pulses: present or diminished - sepsis common; gangrene may develop classification according to Wagner scale Charcot foot: later stages secondar to decreased sensation TX: - standard ulcer management- decried necrotic tissue and promote moist wound healing - offload ulcer from abnormal pressures - shoe modification- use of rocker bottom shoe

Question 75

Pressure ulcer (decubitus)

Answer 75

Caused by unrelieved pressure resulting in ischemic hypoxia and damage to underlying tissue occurs over bony prominences color: red, brown/black, yellow can be painful is sensation intact inflammatory response with necrotic tissue: -hyperemia, fever, increased WBC graded by stages of severity

Question 76

Pressure ulcer scale and treatments

Answer 76

Stage I: - non-blanchable erythema of intact skin - reversible with intervention - TX: pressure, friction and moisture alleviating measures Stage II: - partial thickness skin loss; involves epidermis and dermis - presents as an abrasion, blister or shallow crater - TX: if no infection an appropriate dressing occludes the wound from environment Stage III: - full thickness skin loss; involves damage to or necrosis of subcutaneous tissue but not through the fascia - presents as a deep crater - TX: often requires debridement, dressings and advanced pressure alleviating measures Stage IV: - full thickness skin loss; involves extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures - TX: debridement, dressings, advanced pressure alleviating; surgery and grafting likely Unstageable: -tissue depth is obscured due to slough or escar and extent of damage can't be determined *If the wound is infected or not healing within 2 weeks, then antibacterial agents or a tx modality may be indicated

Question 77

bone healing

Answer 77

occurs within a few days if the wound is not infected process involves considerable hemorrhage, followed by proliferation of osteoblasts, then to the formation of a callus at about a week, which eventually remodels into bone

Question 78

albumin

Answer 78

normal: 3-5-5-5 g/dL

Question 79

methods of debridement

Answer 79

``` autolytic enzymatic mechanical sharp surgical ```

Question 80

autolytic debridement

Answer 80

natural debridement promoted under occlusive or semi occlusive moisture-retentive dressings that results in solubilization of necrotic tissue only by phagocytic cells and by proteolytic and collagenolytic enzymes inherent in the tissues Contraindications: - infected wounds - immunosuppressed patients - dry gangrene or dry ischemic wounds

Question 81

Enzymatic debridement

Answer 81

a selective method of chemical debridement that promotes liquefaction of necrotic tissue by applying topical preparation of collagenolytic enzymes to those tissues Indications: - moist necrotic wounds - eschar after cross hatching - homebound patients - can't tolerate surgical debridement Contraindications: - ischemic wounds unless adequate vascular status - dry gangrene - clean, granulated wounds

Question 82

mechanical debridement

Answer 82

nonselective method removes foreign material and contaminated tissue by physical forces -wet-to-dry gauze dressing, whirlpool, suction -may remove healthy tissue Indications: -wounds with moist necrotic tissue or foreign material present Contraindications: -clean, granulated wounds

Question 83

sharp debridement

Answer 83

selective method -uses sterile instruments that remove only necrotic wound tissue without anesthesia and with little or no bleeding Indications: -excision of leathery eschar Contraindications: - clean wounds - advancing cellulitis with sepsis - infection - anticoagulant

Question 84

surgical debridement

Answer 84

deep (stage III or IV) or complicated pressure ulcer selective, performed by surgeon - removes most/all necrotic tissue and maybe some healthy tissue - requires anesthesia Indications: - advanced cellulitis with sepsis - immunocompromised patients - threatening infection Contraindications: - cardiac, pulmonary disease or diabetes - severe spasticity

Question 85

delays in wound healing

Answer 85

Intrinsic: -aging, chronic diseases, circulator disease, malnutrition, neuropathy Extrinsic -meds (steroids), necrotic tissue, infection, excessive pressure, wrong dressing choice Chronic inflammation can persist for months, years and delay wound healing due to necrotic tissue, colonization, infection or foreign materials present within the wound. - often recognized by a wound not healing normally and/or a halo of redness or purple hue from an excessive release of histamine due to overreactive macrophages and mast cells - source of inflammation must be resolved before haling can begin

Question 86

types of union

Answer 86

Primary union: - no major loss of CT - sealing by blood clot within hours - epithelialization and fibroblast proliferation 1-3 days - subsequent formation of collagen tissues over period of weeks - collagen eventually loses its excess vascular supply and tissue strength increases by end of 2 months Secondary union: - prolonged process of dermal healing that results from necrosis of tissue due to inflammation or traumatic destruction (pressure ulcer) - delay of wound healing unless dead tissue and debris are removed from wound - "beefy red" appearance indicates healthy healing and no debridement or chemical antibacterial agent needed - moist wound healing should be promoted except in the presence of infection Tertiary (delayed primary) union: - dela in suturing of a site 5-7 is indicated in the presence of wound contamination, large tissue loss, or excessive edema - healing sequence is similar to an injury treated with a primary union except for a delay of about a week

Question 87

wound dressings

Answer 87

Functions: - protect wooden from contamination and trauma - permit application of meds - absorb drainage - debride necrotic tissue - enhance healing Dressing choices for a wound are based on 3 primary characteristics: 1- color 2- depth 3-exudate production Dressings:: - gauze - occlusive dressings - alginates - films - foams - hydrocolloid - hydrogels - nonadherent - semirigid - transparent

Question 88

modalities that promote wound healing

Answer 88

iontophoresis with zinc or histamine US to speed up healing - low intensity, pulsed - 3x/week Estim - increase wound healing - reduce bacterial contaminants - high volt pulsed current (HVPC) - anode used to promote epithelial cell migration and for reactivation of inflammatory phase - cathode used to promote granulation, control inflammation and inhibit certain bacteria Wound VAC - negative pressure system - indicated when wound isn't closing, lack of arterial perfusion or when excessive exudate that can't be controlled with dressing - applied continuously and in presence of infection

Question 89

transparent films

Answer 89

clear, adhesive, semipermeable membrane -permeable to oxgen and moisture vapor Indications: - stage I and II pressure ulcers - autolytic debridement Advantages: - visual evaluation of wound without removal - impermeable to external fluids and bacteria - transparent and comfortable - promote autolytic debridement - minimize friction Disadvantages: - nonabsorptive - difficult application - not used on wounds with fragile skin or infection or copious drainage

Question 90

Hydrocolloid dressings

Answer 90

adhesive wafers containing hydroactive/absorptive particles that interact with wound fluid to form a gelatinous mass over wound bed. - may be either occlusive or semi-occlusive - available in paste form as a filler for shallow cavity wounds Indications: - protection of partial thickness wounds - autolytic debridement of necrosis or slough - wounds with mild exudate Advantages: - maintains moist wound environment - excellent bacterial barrier - nonadhesive to healing tissue - conformable - supports autolytic debridement - reduces pain - easy to apply, time saving - diminishes friction Disadvantages: - not used over infection - nontransparent - may soften and change shape with heat/friction - not for wounds with heavy exudate or with fragile surrounding tissue - dressing edges may curl change 3-7 days and as needed with leakage

Question 91

Hydrogel dressings

Answer 91

water or glycerine based gels - insoluble in water - available in solid sheets, amorphous gels, or impregnated gauze - absorptive capacity varies Indications: - partial and full thickness burns - wounds with necrosis and slough - burns and tissue damaged by radiation Advantages: - soothing/cooling - fill dead space - rehydrate dry wound beds - promotes autolytic debridement - provides min to mod absorption - conforms to wound bed - transparent to translucent - amorphous form can be used for infection Disadvantages: - most require secondary dressing - not used for heavily exudated wounds - may dry out and then adhere to wound bed - may macerate surrounding skin dressing changes every 8-48 hours

Question 92

foam dressings

Answer 92

semipermeable membranes that are either hydrophilic (absorb moisture) on in inside and hydrophobic on the outside -vary in thickness, absorptive capacity and adhesive properties Indications: - partial and full thickness wounds with min to moderate excudate - secondary dressing for wounds with packing to provide additional absorption - provide protection and insulation Advantages: - insulate wounds - provide padding - most are non adherent - conformable - manage min-heavy exudate - easy to use - some newer products designed for deep cavities Disadvantages; - nontransparent - nonadherent require secondary dressing, tape or net to hold in place - poor conformability to deep wounds - not for use with dry eschar or wounds without exudate change 1-5 days

Question 93

Alginate dressing

Answer 93

soft, absorbent, non woven dressings derived from seaweed that have a fluffy cotton like appearance - react with wound exudate to form a viscous hydrophilic gel mass over the wound area - available in ropes and pads Indications: - wounds with mod-large amounts of exudate - wounds with combo exudate and necrosis - wounds that require packing and absorption - infected and noninflected exuding wounds Advantages: - absorb 20x their weight in drainage - fill dead space - support debridement in presence of exudate - easy to apply Disadvantages: - require secondary dressing - not recommended for dry or lightly exudating wounds - can dry wound bed may use dry gauze or transparent film as secondary dressing change 8 hours to 2-3 days

Question 94

Gauze

Answer 94

made of cotton or synthetic fabric that is absorptive and permeable to water and oxygen - may be used wet, moist, dry or impregnated with petrolatum, antiseptics, or other agents. - com in varying weaves and with different sizes Indications: - exudative wounds - wounds with dead space, tunneling or sinus tracts - wounds with combo exudate or necrotic tissues 1-Wet-to-dry: mechanical debridement of necrotic tissue 2-Continous dry: heavily exudating wounds 3- Continuous moist: protection of clean wounds -autolytic debridement of slough/eschar -delivery of topical needs Advantages: - readily available - used with appropriate solutions- gels, saline, antimicrobials to keep wound moist - can be used on infected wounds - good mechanical debridement if properly used - cost effective - effective delivery of topicals if kept moist Disadvantages: - delayed healing if used improperly - pain on removal (wet to dry) - labor intensive - require secondary dressing - avoid direct contact with granulating tissue lack loosely or compromises BF and delays closure

Question 95

semirigid dressing

Answer 95

unna boot is a pliable, non stretchable dressing impregnated with ointments used for venous insufficiency ulcers to control for edema and help with healing