Overview and Assessment Flashcards
1
Q
Three layers of human skin
A
epidermis, dermis, subcutaneous tissues
2
Q
Dermis is ___ layers of ____________ tissue
A
2 layers; vascular
3
Q
The epidermis is (avascular, vascular)
A
avascular
4
Q
Adipose and fascia are in which layer of skin?
A
subcutaneous
5
Q
Which skin layer is for protection?
A
subcutaneous
6
Q
Epidermis has how many layers?
A
5
7
Q
What is the “horny” layer of the epidermis?
A
stratum corneum
8
Q
Which layer of the epidermis is the physical barrier from trauma and infection?
A
stratum corneum
9
Q
The outermost layer of the epidermis
A
stratum corneum
10
Q
Skin layer beneath the stratum corneum
A
stratum lucidum
11
Q
How did the stratum lucidum get its name?
A
looks clear under a microscope
12
Q
Skin layer beneath the stratum lucidum
A
stratum granulosum
13
Q
Skin layer beneath the stratum granulosum
A
stratum spinosum
14
Q
Skin layer beneath the stratum spinosum
A
stratum basal
15
Q
Stratum spinosum consists of several rows of _______________ that appear __________ under a light microscope
A
mature keratinocytes; spiny
16
Q
Skin layer beneath the stratum basal
A
basement membrane
17
Q
Keratin is produced by what layer of epidermis?
A
stratum basal
18
Q
As the basal membrane begins breaking down, what happens?
A
skin becomes more susceptible to wounds (blisters, friction)
19
Q
Since the epidermis is avascular, how does it receive blood supply?
A
from the dermis through the basement membrane via diffusion
20
Q
Melanocytes produce ___________ protecting from _______________.
A
melanin; UV rays
21
Q
What do the melanocytes do?
A
produce melanin protecting from UV rays
22
Q
Merkel cells are ___________ for _____________.
A
mechanoreceptors; light touch
23
Q
Langerhans cells present in ______________ that help _________________ by _______________________________.
A
deeper layers; fight infection; attacking and engulfing foreign materials
24
Q
What do hair follicles help with?
A
temperature regulation
25
Each hair follicle contains ______________ secreting ____________ to ____________________________.
sebaceous gland; sebum; lubricate the skin and hair
26
Hair follicles are what kind of keratin?
soft
27
Nails are what kind of keratin?
hard
28
Epidermis provides what kind of protection? (functional vs. non-functional)
functional
29
Sudiferous glands are
sweat glands
30
Where are sudiferous glands located?
everywhere but lips and ears
31
Epidermal functions
- barrier to injury, contaminants and light
- prevents dehydration / retains fluid
- produces melanin / coloration
- light touch sensation
- assists with excretion
- temperature regulation
32
Dermal functions
- Houses epidermal appendages
- Assists with infection control
- Hair production
- Assists with infection control
- Houses sensory receptors
- Supplies nutrients and oxygen to epidermis
- Vitamin D production in response to sunlight
- Supplies sebum to lubricate
33
Structural changes with aging
- flattening of dermal-epidermal junction pegs
- epidermal thinning
- loss of elastin fibers
- dermal atrophy
- diminished vascularization
34
Stratum corneum is how much thickness of the epidermis?
3/4 - it is the thickest layer!
35
Subcutaneous tissue functions
- insulation
- support
- padding
- energy storage for other layers of the skin
36
Functional changes with aging
- Increased skin permeability
- Decreased inflammatory response
- Decreased elasticity
- Decreased sweat and sebum production
- Decreased synthesis
- Impaired sensory perception
37
Why do you get poor blood supply with aging?
nutrition, weight, gravity
38
The very first thing (phase) that happens when a wound is opened
inflammatory phase
39
How long does the inflammatory phase last?
3-7 days
40
What is the goal of the inflammatory phase?
to provide hemostasis and clear away bacteria, foreign material and dead tissues
41
Inflammatory phase - hemostasis
platelet function
42
Inflammatory phase - vasodilation
meet metabolic demands
43
Inflammatory phase - mast cells
histamine response
44
Inflammatory phase - neutrophils
phagocytic, fight bacteria and enhance antibiotic function
45
Inflammatory phase - macrophages
phagocytic, stimulates fibroblast activity for proliferative phase
46
Why do the macrophages have to show up?
to call in the next phase
47
Inflammation - vascular response
- injury
- transudate leaks into interstitial spaces
- vasoconstriction
- platelets aggregate at injury site
- activated platelets release chemical mediators
- vasodilation (within 30 min of vasoconstriction)
48
What causes exudate in the vascular response of inflammation?
vasodilation
49
What do macrophages call in?
fibroblasts
50
Define margination
slower moving PMNs are pushed to sides of vessel walls
51
Define diapedesis
PMNs adhere to endothelium forcing their way into interstitial spaces by extending footlike projections (pseudopods) through narrow openings with vessel walls
52
Define chemotaxis
PMNs migrate toward zone of injury guided by chemical gradient formed by bacterial toxins, dead or dying cells and changes in local pH
53
PMNs stands for
Polymorphonuclear Neutrophils
54
PMNs secrete
- chemotactic agents and mediators of inflammation
| - enzymes to break down damaged tissues and kill bacteria
55
PMNs secrete chemotactic agents and mediators of inflammation in order to
- attract more PMNs
- stimulate fibroblast migration
- induce vascular growth
56
When do the monocytes come in?
after the PMNs
57
Once in the interstitium, monocytes are called
macrophages
58
How do monocytes direct the repair process?
- Signal extent of injury
- Attract more inflammatory cells
- Produce growth factors
59
Monocytes secrete
- nitrous oxide
| - bactericidal enzymes
60
Mast cells produce
chemical mediators that attract and activate inflammatory cells
61
When should we use hydrogen peroxide?
only during the inflammatory phase
62
cytokines mediate multiple process including
- cell growth
- migration
- activation
- demolition
63
cytokines are
growth factors
64
What does fibrinolysin do?
dissolves clots and plugs
65
After how many days should you start to see less "red hot and swollen"
3-7 days
66
What does hemosiderin indicate?
poor circulation from the veins ???
67
What are the "stars" of the proliferative phase?
fibroblasts
68
What phase is stimulated by the inflammatory phase?
proliferative/granulation phase
69
The proliferative/granulation phase is stimulated by
the inflammatory phase
70
True/False: The proliferative/granulation phase overlaps with the inflammatory phase.
True
71
Fibroplasia
fibroblast synthesis for granulation tissue
72
Endothelial budding
vessels from surrounding tissue migrate to supply nutrients
73
Myofibroblasts
wound contraction at margins
74
Collagen matrix consists of
- collagen
- hyaluronic acid
- fibronectin and elastin formation
75
Angioblasts
endothelial cells that make up blood vessel walls adjacent to zone of injury
76
Angioblasts bud and grow into affected area directed by
- local tissue ischemia
- vascular endothelial growth factor
- chemical mediators
77
MMPs stands for
Matrix Metalloproteases (MMPs)
78
What produces MMPs?
- neutrophils
- macrophages
- fibroblasts
- keratinocytes
79
What do MMPs do?
degrade debris formed during inflammatory phase leaving a defect
80
What kind of tissue is granulation tissue?
vascularized connective tisue
81
ECM stands for
Extracellular Matrix
82
Surface cell receptors called _______________ help cells _______________ and ______________ to the ____________.
integrins; recognize; reversibly bind; ECM
83
Myofibroblasts
actin-rich fibroblasts with contractile proteins to pull on ECM and draw wound edges closer together
84
Drawing wound edges closer together is called
contraction
85
What is wound contraction? What is responsible for this?
Drawing wound edges closer together; myofibroblasts
86
What guides the epithelial cells at the wound margins to migrate to the center of the wound?
chemotactic agents
87
If granulation tissue is not "bumpy", pt is deficient in
protein
88
In the epithelialization/maturation phase, what migrates?
epithelial cells
89
In the epithelialization/maturation phase, there is a balance between
collagen lysis and collagen synthesis
90
There is a balance between collagen lysis and collagen synthesis in what phase?
epithelialization/maturation phase
91
In the epithelialization/maturation phase, collagen aligns how?
to applied stress
92
Since collagen aligns to applied stress in the epithelialization/maturation phase, what is important to do?
ROM and positioning
93
Scar formation and remodeling occurs in what phase?
epithelialization/maturation phase
94
How long does the epithelialization/maturation phase last?
6 months to 2 years
95
Tensile strength of wound will not exceed
70-80% of the original skin
96
Inadequate stimulus for repair results in
gradual loss of tissue, leading to inadequate response
97
Reasons for impaired inflammation
- Inadequate stimulus for repair
| - Inadequate perfusion / ischemia
98
At what phase of the inflammatory process should ROM and positioning begin?
day 1 of inflammatory
99
Reasons for impaired proliferation/granulation
- Increased amounts of inflammatory cytokines
- Low levels of growth factor cytokines
- Inadequate substrate availability (protein, vitamins, minerals)
- Inadequate oxygenation
- Disruption of pH and temperature
100
Intrinsic factors affecting healing
- Age
- Chronic disease
- Immunosuppression
- Sensory impairment
- Presence of foreign body
- Tissue perfusion
- Malnutrition
101
Extrinsic factors affecting healing
- Smoking
- Medications
- Nutrition
- Chemotherapy / Radiation Rx
- Stress
- Trauma
- Infection or microbial overload
102
In normal wound healing, full-thickness loss heals how?
by scar tissue formation
- inflammation
- granulation / proliferation
- epithelialization
- maturation / remodeling
103
Reasons for impaired remodeling/maturation
- imbalance of lysis / synthesis activity
104
What types of ulcers are staged? graded?
pressure; diabetic
105
What is undermining?
Where the wound edge is detached and Q-tip can be slipped in and wiggled around.
106
Iatrogenic factors affecting healing
- local ischemia
- treatment choices
- trauma
107
Wound measurements are universally recorded in what order?
Length x width x depth
108
Wounds are universally measured in what scale?
centimeters
109
Clock vs Perpendicular method of measuring wound size.
Clock is more objective and consistent
110
What is tunneling?
When two wounds "communicate"
111
What is a fistula?
A tunnel with no "exit" - may go straight to an organ or bone
112
Scab vs. eschar
A scab is just dried blood, eschar is dead tissue
113
Types of drainage
- serous
- serosanguinous
- sanguinous
- purulent
114
Sanguinous drainage is
bloody
115
Serous drainage is
- clear
- thin
- watery
116
Serosanguinous drainage is
clear with a bloody tint
117
Wound closure - primary intention
edges of incision are physically approximated and held in place
118
Wound closure - secondary intention
- granulation tissue matrix must be built and wound contraction achieved
- unable to approximate wound edges
119
Wound closure - delayed primary intention (tertiary intention)
- combination of primary and secondary intentions
| - contaminated wounds
120
Short term goals in wound healing
- Promote moist clean wound environment
- Reduce / localize erythema - measure
- Reduce / control edema with elevation or compression - measure
- Shift drainage from purulent to serous
- Reduce drainage from copious to mod/min
- Pain control with dressing or positioning choices
- Improve periwound integrity to promote wound contraction
- Soften necrosis to prepare for debridement
- Reduce risk factors for infection
- Control drainage with dressing choices to protect periwound
- Education
121
Long term goals in wound healing
- Reduce necrosis by percentage
- Promote granulation by %
- Reduce size of undermining, tract, or tunnel
- Reduce wound size by cm
- Tissue perfusion and oxygenation are enhanced
- Wound and soft tissue healing is enhanced
- Complications are reduced
122
Examples of linear wounds
paper cut, surgical incision, small cutaneous wounds
123
Signs of infection
- Induration
- Fever
- Erythema
- Edema
- Odor
- Purulence
- Increased pain
- Friable tissue
- Change in color
124
What is induration?
hardness
125
What is friable tissue?
wipes away, has too much bacteria
126
What does a change in color of a wound indicate?
too much bacteria
127
Long term goals in healing diabetic wounds
- Loading on a body part is decreased
- Protection of a body part is increased
- Tolerance to activities is increased
- Weight bearing status is improved
- Awareness and use of community resources is improved
128
Long term goals in healing wounds caused by vacular insufficiency
- Pain decreased
- Protection of a body part is increased
- Sense of well-being is increased
- Soft tissue swelling, inflammation, or restriction is reduced
- Tolerance to positions and activities is increased
129
Purulent drainage is
- cloudy
| - white
130
What happens in epiboly?
Edges of wound have rolled under and healing has plateaued
131
What is it called when the edges of a wound have rolled under and healing has plateaued?
epiboly
132
Maceration results in
- moist wound edges
- white
- fragile
- peeling
133
The epidermis contains what types of cells?
melanocytes, melanin, Langerhans' cells
134
The dermis contains what types of cells?
fibroblasts, macrophages, WBCs, mast cells
135
What are the fat tissues of the subcutaneous layer for?
energy
136
In which skin layer are hair follicles, sebaceous, and sweat glands located?
dermis
137
A localized build up of cells in the stratum corneum due to pressure or friction is called
callus
138
In what layer of skin does a callus occur?
stratum corneum
139
2 Layers of the dermis
- papillary
| - reticular
140
The papillary dermis is the ground substance that
conforms to the contours of the stratum basal
141
What is the purpose of a callus?
protection from trauma
142
What is a callus?
a localized build up of cells in the stratum corneum due to pressure or friction
143
Layers of the epidermis from superficial to deep
- Stratum corneum
- Stratum lucidum
- Stratum granulosum
- Stratum spinosum
- Stratum basal
144
What is the "last layer" of the epidermis to contain living keratin cells?
stratum granulosum
145
The basement membrane is the "scaffolding" between what 2 skin layers?
epidermis and dermis
146
The papillary dermis helps the _______________ to _____________ the dermis and _________________.
basement membrane; anchor; protect epidermal appendages
147
Blisters occur at which area layer of skin? Why?
papillary dermis; due to friction between layers
148
What does the reticular layer of the dermis provide?
structural support
149
Fascia and muscles beneath the subcutaneous tissue provide
further structure and padding
150
Regarding the vascular response of inflammation, what happens when transudate leaks from vessels into interstitial spaces?
localized edema
151
Regarding the vascular response of inflammation, what is vasoconstriction mediated by?
serotonin, norepinephrine, ANS
152
Regarding the vascular response of inflammation, what activates the platelets to aggregate at the injury site?
damaged endothelial cells and exposed collagen
153
cytokines
signaling proteins
154
What do growth factors control?
cell growth, differentiation, and metabolism
155
What do chemotactic agents do?
attract cells necessary for repair
156
Regarding the vascular response of inflammation, what triggers vasodilation?
- histamine
- plasma-active substances
- platelet-derived vasoactive substances
157
Regarding the vascular response of inflammation, histamine released by mast cells increases
vessel wall permeability for short term vasodilation
158
Regarding the vascular response of inflammation, why are prostaglandins released?
for long term vasodilation
159
In the cellular response of inflammation, increased vessel wall permeability causes
decrease in blood volume
160
Macrophages stimulate what phase?
proliferative
161
Enzymes that accelerate the demise of damaged cells are called
mast cells
162
Regarding the cellular response of inflammation, what adheres to vessel walls and moves into the interstitial spaces?
leukocytes, erythrocytes, and platelets
163
Neutrophils and macrophages phagocytize microorganisms, then excrete
- ascorbic acid
- lactic acid
- hydrogen peroxide
164
What is the goal of the proliferative/granulation phase?
to replace lost dermal tissue with scar tissue
165
What occurs during the proliferative phase?
- Fibroplasia
- Endothelial budding
- Collagen matrix of collagen, hyaluronic acid, fibronectin and elastin formation
- Myofibroblasts
- Angiogenesis
- Granulation tissue formation
166
Fibroblasts secrete __________________ and lay down the ____________________.
hyaluronic acid and fibronectin; ECM
167
Fibroblasts are guided by
- chemotactic agents
| - low oxygen tension
168
What does the ECM "technically" do?
mediates wound contraction
169
What provides a scaffolding for contact guidance to move cells into the wound area?
ECM
170
Inadequate perfusion / ischemia leads to
vascular insufficiency leading to muted hemostasis and a muted cascade initiation
171
In normal wound healing, partial thickness / superficial loss heals by
re-epithelialization / regeneration
172
In normal wound healing of full-thickness loss, how will the wound edges be?
soft and gradually adhering
173
When assessing skin, what can hair pattern tell you?
where blood is flowing to
174
ABI stands for
Ankle-Brachial Index
175
ABI =
ankle systolic pressure / brachial systolic pressure
176
ABI values
1 = normal
.8-.9 = intermittent claudication
.5-.8 = significant occlusion (compression contraindicated)
>1 - non-compressible arteries, calcification
177
The ABI is invalid for what types of pts?
diabetics
178
What ABI values contraindicate compression
1
179
Wounds besides pressure and diabetic ulcers are "graded" how?
- superficial thickness
- partial thickness
- full thickness
180
superficial thickness
epidermis removed
181
partial thickness
epidermis and part of dermis removed
182
full thickness
epidermis and dermis removed to/through subcutaneous tissue or deeper
183
What must be done in the case of epiboly?
- must promote inflammatory phase by releasing edges
| - debridement or silver nitrate
184
Options for correction of maceration
- choose more absorptive dressing
- increase frequency of dressing change
- utilize skin barriers / skin prep
185
Long term goals in healing pressure ulcers
- Loading on a body part is decreased
- Protection of a body part is improved
- Sense of well-being is improved
- Tolerance to positions and activities is increased
186
Long term goals in wound healing in all patients
Look it up I'm sick of typing these long-winded goals that are all the same and mostly common sense - p. 16 slide 3
