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Flashcards in Integumentary Deck (95)
1

Indolent =

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

2

induration=

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

3

maceration=

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

4

purulent=

indicates a wound that contains pus and is infected

5

Functions of the skin

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

6

layers of the skin

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

7

appendages of the skin

Hair
-terminal hair
-vellus hair

Nails

Sebaceous glands

Sweat glands

8

sebaceous glands

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

9

sweat glands

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

10

Dermatitis

"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)

11

Bacterial infections

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

1- impetigo
2-cellulitis
3-abscess

12

Impetigo

superficial bacterial skin infection caused by staphylococci or streptococci

associated with inflammation, small pus filled vesicles, itching

contagious; common in children and elderly

13

Cellulitis

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

14

Abscess

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

15

List of Vial infections

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

16

Herpes 1

herpes simplex

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

a cold sore or fever blister

17

Herpes 2

common cause of vesicular genital eruption

spread by sexual contact

in newborns may cause meningoencephalitis; may be fatal

18

Herpes zoster

"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

19

warts

common, benign infection by HPVs

transmission through direct contact

20

Fungal infections

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

21

Parasitic infections

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

22

List of Immune disorders of the skin

1- psoriasis

2-lupus erythematosus

3-scleroderma

4-polymyositis (PM)

23

psorasis

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)

24

lupus erythematosus

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

25

long term risks with corticosteroids

immunosuppression
osteoporosis
myopathy
tendon rupture
diabetes
gastric irritation
low potassium

26

scleroderma

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

27

CREST syndrome

Calcinosis
Raynaud's
Esophageal dysfunction
Sclerodactyly
Telangiectasias

28

polymyositis

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

29

benign skin tumors

seborrheic keratosis
-removed with cryotherapy

actinic keratosis: flat, round, irregular
-precancerous- can lead to squamous cell carcinoma

common mole/benign nevus
-proliferation of melanocytes

30

Malignant skin tumors

basal cell carcinoma

squamous cell carcinoma

malignant melanoma

kaposi's sarcoma

31

basal cell carcinoma

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

32

squamous cell carcinoma

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

33

malignant melanoma

tumor arising from melanocytes

clinical manifestations: ABCDEs
-Asymmetry
-Border
-Color
-Diameter >6mm
Elevation/Evolution

34

contusion

"bruise"
skin is not broken
pain, swelling, discoloration

immediate cold pack can limit effects

35

eccymosis

bluish discoloration of skin caused by extravasation of blood into the subcutaneous tissues

result of trauma to underlying blood vessels or fragile vessel walls

36

petechiae

tiny red/purple hemorrhagic spots on the skin

37

abrasion

scraping away of skin

38

laceration

an irregular tear of the skin
torn, jagged wound

39

pruritus

itching

common in diabetes, drug hypersensitivity, hyperthyroidism

40

turgur

lift skin on back of hands
indicates hydration status sss

41

examination of skin

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

42

uticaria

smooth, red, elevated patches of skin
"hives"

indicative of an allergic response to drugs or infection

43

xeroderma

excessive dryness of skin with shedding of epithelium

can indicate deficiency of thyroid function, diabetes

44

edema can indicate:

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

45

change in nails

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

46

changes in skin color

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)

47

changes in skin temperature

abnormal heat:
-febrile condition
-hyperthyroidism
-mental excitement
-excessive salt intake

abnormal cold:
-poor circulation or obstruction (vasomotor spasm, thrombosis, hypothyroidism)

48

hidrosis

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

49

Burn wound zones

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

50

Burn would classification

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:

51

1st degree burn

"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

52

2nd degree burn: superficial partial thickness burn

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

53

2nd degree burn: deep partial thickness burn

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

54

3rd degree:

"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)

55

4th degree burn

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

56

complications of burn injuries

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

57

epithelial healing:

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

58

dermal healing

results in scar formation (injured tissue is replaced by CT)

scars are initially red or purple, later white

59

healing phases

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

60

Hypertrophic scarring

raised scar that stays within the boundaries of the burn wound is characteristically red, raised, firm

collagen production rate exceeds breakdown

61

Keloid scarring

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

62

Hypotrophic scarring

flat and depressed below the surrounding skin

63

Burn management:

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

64

topical meds for burns

ointments:
-bacitracin
-polymyxin B
-neomyxin

Silver sulfadiazine

sulfamylon- penetrates through eschar

65

dressings for burns

Functions:
prevent bacterial contamination
prevent fluid loss
protect wound
may additionally limit ROM

Dressings:
silver impregnated
hydrogels
petroleum-impregnated
gauze

66

debridement

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

67

burn surgery

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

68

Skin grafts

types?

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

69

compression therapy for burns

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

70

PT for burns

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


71

Splinting and positioning burn wounds


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

72

Venous ulcers

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

73

Arterial ulcers

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

74

diabetic ulcer

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

75

Pressure ulcer (decubitus)

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

76

Pressure ulcer scale and treatments

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

77

bone healing

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

78

albumin

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

79

methods of debridement

autolytic
enzymatic
mechanical
sharp
surgical

80

autolytic debridement

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

81

Enzymatic debridement

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

82

mechanical debridement

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

83

sharp debridement

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

84

surgical debridement

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

85

delays in wound healing

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

86

types of union

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

87

wound dressings

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

88

modalities that promote wound healing

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

89

transparent films

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

90

Hydrocolloid dressings

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

91

Hydrogel dressings

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

92

foam dressings

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

93

Alginate dressing

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

94

Gauze

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

95

semirigid dressing

unna boot is a pliable, non stretchable dressing impregnated with ointments

used for venous insufficiency ulcers to control for edema and help with healing