Integumentary system Flashcards
(54 cards)
What is the rule of 9s?
This refers to the method to determine % of body suffering burns: Head and neck- 9% Ant trunk - 18% Post trunk - 18% both anterior UE - 9% both post UE - 9% Genitals 1% Both ant LE 18% Both post LE 18%
How does the rule of 9s change for age 1-10 year old
Take 9% off the lower extremities and add to the head and neck - add 1% back each year until 9 years old.
What is the Wagner Ulcer classification scale?
0- no open lesion, healed ulcer
1 - Superficial ulcer
2. Deep ulcer including subcutanous tissue, may expose bone, tendon, mm
3. Deep ulcer with OM
4. Gangrene of digit
5. Gangrene of foot requiring disarticulation
What are the stages for pressure ulcers
I - intact skin, bony prominence, non-blanchable, pain/itch
II - Partial thickness tissue loss, shallow open ulcer, red wound bed, blister
III- Full thickness tissue loss into subcutanous layer - tunneling
IV - Full thickness exposed tendon, muscle or bone, eschar, undermining, tunneling,
Unstagable - full thickness tissue loss covered with eschar - needs debriding to stage.
What are the types of exudate?
Serous - clear, light, thin, normal
Sanguineous - red colour, thing, watery, blood, may be brown if dried - normal (moderate amount or greater indicates tissue damage)
Serosanguinous: light red or pink, thin and watery, normal in healthy healing tissue
Seropurulent - cloudy or opaque with yellow or tan colour, thin and watery, Early sign of infection
Purulent - yellow or green colour, thick, viscous indicates infection
What are the types of odour associated with wounds? What are they caused by
Pseudomonas infection - sweet odour, thin, foamy green drainage
Clostridium - strong pungent odor associated with tissue necrosis
Putrescine -pungent can cause vomiting, rotten smell
Caused by tissue degredation, necrosis or anaerobic bacteria
What are the 9 things that are examined when treating a wound
- Examine for tunnelling
- report colour and tissue involved record presence of granulation or epithelialization
- Temperature
- Girth (can use volumetric measures for girth but not for wound volume
- Viability of periwound tissue - halo, warmth, swelling
- Sensory integrity
- signs of infection
- wound scar tissue - banding, pliability, texture
- photographic records - wound appearance.
What are the 4 types of burn
Thermal - from conduction or convection
Electrical - Complications include arrthythia, resp arrest, renal failure, neuro damage
Chemical - Reactions conitnue until chemical is diluted
Radiation - altered DNA complications include blistering, desquamation, non-healing wounds, tissue fibrosis, discoloration, new malignancies
What are the three classifications of burn zones
Zone of coagulation - irreversibly injured, cell death
Zone of stasis - cells injured, may die without specialised treatment
Zone of hyperemia - minimal cell injury, should recover
What are the signs of a 1st degree burn and what is the rate of healing - superficial burn
Redenss that lasts >20 minutes, no blistering, epidermis only, 3-7 days
What are the signs of a 2nd degree burn and what is the rate of healing - Superficial partial thickness burn
Blisters, separation between dermis and epidermis. Pain with more fluid loss. Local circulation disrupted. 7-21 days
What are the signs of a 2nd degree burn and what is the rate of healing - Deep partial thickness burn
Red or white appearance, blistering, severe pain, severe damage to dermis and epidermis. Injury to nerve endings hair follicles, sweat glands. 21-28 days
What are the signs of a 3rd degree burn- Full thickness burn
Through dermis and depidermis, may involve subcutanous tissue. Damage to muscle and tendons causing risk for developing contracture. Gray, white or black appearance, eschar.
What are the two types of scarring associated with a full thickness burn?
Hypertrophic scar - raised scar that stays within the boundaries of burn wound
Keloid scar - raised scar that extends beyond boundaries of original burn wound
What is a 4th degree burn
Electrical burns - large thermal burn where current exits the body and a smaller injury at the entrance point. Extensive tissue damage.- destruction of vascular system.
What are the characteristics of an arterial insufficiency ulcer?
- lower third leg, toes, web spaces, lat malleolus
- Smooth edges, well defined, deep
- Minimal exudate
- painful
- diminished or absent pedal pulses
- Normal or no edema
- Decreased skin temperature
- thin, shiny skin, hair loss, yellow nails
- Leg elevation increases pain
Rx: protect limb, inspect daily, avoid leg elevation, appropriate shoes with seamless socks
What are the characteristics of a venous insufficiency ulcer?
- Proximal to medial malleolus
- irregular shape, shallow
- mod to heavy exudate
- mild to mod pain
- normal pulses
- increased edema
- normal skin temp
- flaking, dry skin brownish colour
- leg elevation decreases pain
- limb protection, risk reduction, compression, elevation of legs, AROM ex, shoes and socks appropriate
What are the characteristics of a neuropathic ulcer?
Areas exposed to pressure or shear during WB
- Well defined, oval or circle, little necrosis, good granulation
- low to mod exudate
- no pain
- diminished or absent pulses
- normal edema
- decreased skin temp
- dry, inelastic, shiny skin, decreased or absent sweat and oil
- loss of protective sensation
Rx: repositioning 2 hourly in bed, manage excess moisture, inspect skin daily
What are the characteristics of a pressure ulcer?
- areas of prolonged pressure - bony prom
- Initially bruising or purple blisters
- no exudate
- mild pain
- normal pulses
- no edema
- increased skintemp
- shearing forces, moisture, temperature, friction, malnutrition
- Reposition every two hours
What are the 6 types of wound?
Abrasion - shear and friction forces
Avulsion - aka degloving - skin detatched from underlying structures
Laceration - trauma - shear, tension, high force compression
Penetrating - entering the interior of organ or cavity
Puncture - penetrates skin and underlying tissue
Skin tear - trauma to fragile skin
What is dermatitis
Inflammation of skin diagnosed as:
Acute; red oozing, crusting, rash, exudate
Subacute: erythematous skin, scaling, scattered plaque
Chronic: thickened skin, skin marking from scratching, post inflamm pigmentation changes.
Impetigo is..
A bacterial skin infection caused by staph/strep infection Associated with inflammation, small pusfilled vesicles, itchy, contagious. Rx: AB
Cellulitis is…
Bacterial skin infection - strep or staph, poorly defined and widespread. Hot, red edematous. can be contagious. AB elevation, cool wet dressing.
Abscess is
Commonly from a staph infection. Cavity containing pus, surrounded by inflamed tissue, result of localised infection. Will naturally burst out of the skin if left alone. Rx: drain.
