Stared slides

Question 1

Dressing should be?

Answer 1

If its too wet dry it
If its too dry wet it
Drainage drives the dressing decisions

Question 2

Exception to removing necrotic tissue on the lower extremity:

Answer 2

Dry and stable eschar heals
Arterial insufficiency (ABI<0.5)
Patient taking blood thinner medication (does not soften or remove)

Question 3

Wound healing Myths

Answer 3

Traditional myths
Let a scab form
Let it dry out
Wounds should be open to air and sunlight
DSD = dry sterile dressing (wet to dry sterile dressings are not good)

Question 4

What is the definition of burn?

Answer 4

Definition: thermal destruction of skin from direct contact or exposure to a source
Thermal
Chemical
Electrical
Radiation

Question 5

how do you measure the depth?

Answer 5

Depth is function of temperature or source of energy and duration of exposure

Question 6

Epidemiology

Answer 6

Peak incidence children 1-5 yo
Scalds bimodal
Adults and adolescents
Flammable liquids
Men ages 16-40 higher incidences
House fires 85% of deaths
Overall incidence down-prevention

Question 7

Risk factors for burn?

Answer 7

Higher incidence for children <4 yo and adults >65yo
Lower income
Psychomotor disorders/alcohol use
Rural locations
Mobile home residence/substandard housing
Occupational
Lack of smoke detectors
Fireworks
Misuse of cigarettes

Question 8

Severity-assessed with:

Answer 8

Risk of infection
Risk of mortality
Risk of cosmetic or functional disability

Question 9

Factors affecting severity:

Answer 9

Burn depth
Burn size
Location
Age of patient
General health
Mechanism of injury

Question 10

how would you measure wound size:

Answer 10

Rule of nines
Lund-Browder (pediatric population)

Question 11

what is the determination of burn sizes

Answer 11

Rule of 9s
18% each leg
18% anterior and posterior trunk
9% each arm
9% for the head
1% perineum
Can give an over estimate of burn wound size
%TBSA
Rule of nines

Question 12

Burn types

Answer 12

Thermal
Electrical
Chemical
Radiation
UV
Ionizing radiation

Question 13

Burn classification

Answer 13

Superficial
Superficial partial thickness
Deep partial thickness
Full thickness

Question 14

zone of injury

Answer 14

Zone of coagulation
Localized in the center of the burn
Area of greatest damage contains non-viable tissue (eschar)
Zone of stasis
Surrounding the zones of coagulation and constraints marginally viable tissue
Zone of hyperemia
Outermost area
Least damaged and heals rapidly

Question 15

acute burn management

Answer 15

American Burn Association’s criteria for admission to a burn center
Partial and full-thickness burns>10% of total body surface area (TBSA) in patients under 10 and 50 years ago.
Partial and full thickness burns >20% TBSA in all other ages groups
Full-thickness burns greater than 5% TBSA in any age group.

Question 16

Burns- Emergency treatment

Answer 16

Treatment
Emergency
Remove person from burn source
CPR
Lavage chemical agent
Local measures
Cold water
Sterile dressings

Question 17

Escharotomy

Answer 17

Excision of the burn through the eschar to allow for edema.
Prevents compression of vital structures
Not to confused with fasciotomy
Excision through the fascia
Usually performed to address compartment syndrome

Question 18

Burns-continued treatment

Answer 18

Debridement of necrotic tissue
Elevation of affected areas
Infection control
Sterile cleansing/dressings
Topical antibiotics
Pain management
Body temperatures maintenance
Nutrition
Skin grafting

Question 19

Role of PT in burn management

Answer 19

Goals:
Contracture prevention
Functional recovery
Interventions:
Postioning
Splinting
ROM
Ambulation/endurance
Gait
ADL’s
Scar management
Pain control

Question 20

What are the positions of comfort and positions of function?

Answer 20

positions of comfort are normally crossed arms and legs in a slouched position

portions of function are in portions for slowing contracture development.

place your patient in positions of function.

Question 21

what do pressure garments look like for burn patients?

Answer 21

Essential for scar management
Earlier the application the better the result
Pressure should be 25-30 mmHg
Decreased vascularity
Decreased collagen deposition
Decreased local edema
May begin pressure therapy with elasticized tubular stockinette
Progress to custom made pressure garments
Warn up to 23 hours/day for 12-18 months

Question 22

Diabetic facts for DFU

Answer 22

Greatest risk for diabetic foot ulcer (DFU) is neuropathy
15% of those with diabetes will have a DFU
Greatest risk for amputation is a DFU
Diabetic amputations >3.3/1000 according to the CDC
25-68% incidence of contralateral amputations within 3-5 years
50% Three year mortality rate
Each amputation costs $25,000-40,000

Question 23

what are the risk factors for DFU

Answer 23

Interrelated/cumulative
PVD
Neuropathy
Sensory
Motor
Autonomic
Mechanical stress
Impaired ROM
Foot deformities
Previous ulcer or amputation
Inadequate footwear
Impaired healing and immune responses
Poor vision

Answer 24

Not nessarily
DFU are a result of
Neuropathy
Mechanical stress
+/- PVD

Question 25

neuropathy in diabetic foot ulcer patients

Answer 25

Most common complication 30-40% affected (type 2); higher with type 1 Symmetrical Affects distal nerves first May be caused by neural ischemia or segmental demyelination Incidence and severity increase with age and duration of disease

Question 26

Sensory neuropathy

Answer 26

Inability to perceive trauma to the feet Sensory loss occurs gradually and is painless Patients may be unaware Paresthesia’s 5.07 semmes-weinstein monofilament= 10 grams of pressure =protective sensation

Question 27

what causes motor neuropathy in diabetic foot ulcers

Answer 27

Paralysis of intrinsic muscles= muscle imbalances Alters weight bearing patterns Increases plantar pressures and shear forces Excessive plantar pressure and shear forces on the metatarsals Loss of intrinsic function-foot less stable during stance

Question 28

What is the sequential process of getting hammer toe?

Answer 28

Contractures – hammer toes- improper weight bearing- into ulcers- infections- osteomyelitis – amputation

Question 29

Autonomic neuropathies have alterations in?

Answer 29

Sweating mechanisms (hydration) Callus formation Blood flow (Vasomotor regulation)

Question 30

abnormal foot function and inadequate footwear

Answer 30

Impaired motion Foot deformities Previous ulcer or amputations Combine with poor footwear and decreased sensations

Question 31

foot deformities with DFU

Answer 31

Plantar flexion contractures Forefoot varus/valgus Neuropathic fractures and dislocation= charcot foot Combined with sensory neuropathy= increased ulceration risk

Question 32

previous ulcers or amputations cause what in patients

Answer 32

Altered skin performance Less elastic Decreased strength Altered foot structure from amputation Predisposing factors causing old injury are still present

Question 33

Neuropathic foot ulcers are associated with what?

Answer 33

Associated with: Morbidity Mortality Financial burden 25x > lower extremity amputation in diabetic people 600,000 annually (80% after foot ulcers) More than ½ get 2nd amp within 3-5 years

Question 34

what are the grades to the wagner classification of diabetic foot ulcers

Answer 34

Grade 0: no ulcer in a high risk foot Grade 1: superficial ulcer involving the full skin thickness but not underlying tissues Grade 2: deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation Grade 3: deep ulcer with cellulitis or abscess formation often with osteomyelitis. Grade 4: localized gangrene Grade 5: Extensive gangrene involving the whole foot

Question 35

what are the layers of the skin?

Answer 35

Two distinct layers Epidermis Dermis Dermal-Epidermal Junction Aka Basement membrane Subcutaneous Aka hypodermis

Question 36

check out slide 9 and explain blanch able and unbalanceable skin

Question 37

what are the functional components of the epidermis

Answer 37

stratum corneum keratinocytes melanocytes Merkel cells Langerhans’ cells basal cells eccrine unit apocrine unit hair folicules nails elations glands

Question 38

what are the cells in the dermis?

Answer 38

fibroblasts collegen elastin macrophages mast cells lymphatic cells blood vessels nerve fibers

Question 39

what are the cells of the subcutaneous tissue

Answer 39

adipose

Question 40

what are the functions of the epidermis?

Answer 40

Protection: infection, shear/friction, water loss, toxic irritants Vitamin D synthesis Thermoregulation Regulation, retention, dissipation Sensation (light touch) Pigmentation (melanocytes)

Question 41

Dermal appendages are?

Answer 41

Hair follicles Sebaceous glands Sweat glands Lined with epithelial cells Epithelial islands

Question 42

review what are the main things that the skin provides? how can injury occur?

Answer 42

Provides thermoregulation Sensation Metabolism Organ of communication and identification Injury can result in: Functional change Physiologic change Body image change Facial skin, along with underlying muscles capable of expressions

Question 43

what are the classifications of skin loss?

Answer 43

Wounds are classified by depth of tissue injury Erosion- loss of superficial epidermis, probably not bleed, redness, repair by local inflammatory response Partial thickness skin loss- loss of epidermis and part of the dermis, bleed, reepithelization for repair Full thickness skin loss- loss of epidermis, dermis extending into subcutaneous/hypodermis, secondary intention repair through scar Full thickness with muscle, tendon, bone

Question 44

what are the skin changes with aging?

Answer 44

Decreased: Epidermal/Dermal thickness Decreased subcutaneous fat Collagen and elastin Size of Rete ridges/pegs Sensation and metabolism Sweat glands Circulation Reduced mast cells Epidermal regeneration Up to 4X slower healing than younger populations

Question 45

what are the characteristics of acute wounds?

Answer 45

planned/unplanned events healing proceeds in a orderly and timely fashion surgical abrasions/lacerations

Question 46

what are the characteristics of chronic wounds?

Answer 46

exists two weeks or longer does not proceed through normal healing tissue processes examples: pressure ulcers and diabetic neuropathic ulcers

Question 47

what are the stages of wound healing?

Answer 47

hemostasis inflammatory phase proliferation phase maturation phase

Question 48

what occurs in the hemostatic phase?

Answer 48

Injury exposes blood to collagen and initates coagulation factor Platelet aggregation causes fibrin clot formation(plug) Platelets release growth factors which attract cells and chemical substances needed for repair