PAM Wound Care

What makes up the integumentary system?

skin, hair, nails, glands (sebaceous & sweat)

How thick is skin?

0.5-4 mm

How many layers of skin are there?

3

What are the layers of skin?

epidermis, dermis, subcutaneous tissue (hypodermis)

What is the epidermis layer?

thin, avascular (no vessels)

What is the dermis layer?

thick, highly vascular (vessels)

What is the hypodermis layer?

connects skin to muscle & bone

Who has thicker skin, men or women?

men

Who has thinner skin, infants/elderly or adults?

infants/elderly

Various parts of the body differ in what?

thickness & blood flow

How does the skin regulate temperature?

increase/decrease sweat and change in superficial blood flow

How does the skin protect the body?

barrier from microorganisms, UV radiation, dehydration, etc.

How does the skin detect sensation?

multiple sensory cells detect pain, temp, and touch

What does the skin excrete?

-heat

-sweat

-water

How does the skin stay immune?

normal loss of epidermal cells removes microorganisms

How is the skin a blood reservoir?

large volumes of blood can be shunted to central organs or muscle prn

How does the skin synthesize vitamin D?

molecules convert to vitamin D when exposed to UV radiation

How do superficial wounds heal?

re-epithelialization occurs within 24-48 hrs; new cells arrive and mature

How do deeper wounds heal?

3 phases of healing: inflammatory response, fibroblastic phase, remodeling phase

What happens during the inflammatory response?

-1 to 10 days

-platelets form clot

-leukocytes & macrophages arrive and phagocytosis takes place (getting rid of bad cells)

-macrophages provide amino acids & sugars for repair

-stimulates fibroblastic activity

Is an inflammatory response normal?

yes

What happens during the proliferative phase?

-3 to 21 days

-granulation begins

-fibrocytes and other cells move to area & secrete collagen which forms immature pink scar tissue

-collagen synthesis begins

What is another name for the proliferative phase?

fibroplastic

What happens during the remodeling phase?

-7 days to 2 years

-scar tissue matures

-may take from 3 days to several months for complete closure to occur

Delayed wound healing is often attributed to what?

an abnormal inflammatory response

What are common causes of a prolonged inflammatory phase?

-re-injury

-infection

-poor tissue

-perfusion

-certain meds

-arterial insufficiency

-altered immune responses

Which wounds rarely have inflammatory characteristics?

chronic wounds

What is primary intention?

superficial wound closed with suture, staples, or adhesives

What are the effects of primary intention?

-heal quickly

-minimal scarring

-uncomplicated

What is secondary intention?

no superficial closure; wound closes on its own

What are the effects of secondary intention?

-ongoing wound care

-larger scars

What is tertiary intention?

complicated wounds that are temporarily left open then delayed closure

What factors can delay wound healing?

-age

-comorbidities

-edema

-harsh or inappropriate wound care

How does age delay wound healing?

-decreased cell activity

-decreased strength of skin

-greater damage from trauma

-lifesyle

-medication

-obesity

-nutrition

-cognition & self care ability

How do comorbidities delay wound healing?

medical complications

How does edema delay wound healing?

decrease O2 to area of edema

How do harsh or inappropriate wound care delay wound healing?

can lead to further damage

How does infection delay wound healing?

-bacteria compete for nutrients

-release other toxins into wound bed

How does lifestyle delay wound healing?

-prolonged standing

-lack of exercise

-cigarettes

How does medication delay wound healing?

-steroids

-NSAIDS

-oral contraceptives

-anticoagulants

How does obesity delay wound healing?

increase skin tension; skin folds

How does nutrition delay wound healing?

good nutrition is essential to healing

How does cognition & self-care ability delay wound healing?

increased risk

What is contamination?

presence of non-replicating bacteria on wound surface; not necessarily infection

What is colonization?

presence & multiplication of microbes without infection

What is infection?

invasion & multiplication of microorganisms in body tissues resulting in local cellular injury

What is an abrasion?

friction/shear typically over a rough surface

What is avulsion?

where the tissue is torn and separated from the victim's body

What is another term for avulsion?

degloving

What is an incisional wound?

created intentionally with scalpel or scissors

What is laceration?

result from shear, tension, or high force compression

What is penetrating?

wound that enters the interior of an organ or cavity

What is a puncture?

wound made by sharp object with high risk of contamination

What is skin tear?

break or rip in fragile outer skin

What is a traumatic wound?

cause by external force

What is a surgical wound?

defect following surgical incision

What happens if a surgical wound has complications?

it may need additional care

What is an arterial insufficiency wound/ulcer?

wound due to lack of blood flow to the extremities

What is the most common arterial insufficiency wound?

distal LE (pretibial area or dorsum of feet)

What are the general recommendations for an arterial insufficiency wound?

-rest

-limb protection

-risk reduction education

-inspect legs & feet daily

-avoid unnecessary leg elevation

-avoid using heating pads or soaking feet in hot water

-wear appropriately sized shoes with clean seamless socks

What are clinical indicators of arterial insufficiency wounds?

-lack of blood supply (intermittent claudication)

-extreme pain; decreased with rest & increased with elevation

-decreased or absent pedal pulses

-decreased temperature of distal limb

-distinct well defined wound edges

-deep wound bed

-cyanosis

What is a venous insufficiency wound/ulcer?

wound due to lack of blood back to the heart

What does venous insufficiency wound often result in?

ulceration

What kind of edema do venous insufficiency wounds have?

hard, non-pitting (brawny)

What are venous stasis ulcers?

-medial malleolus, foot, mid-calf

-usually related to trauma or infection

-leakage of red blood cells

-thin skin, loss of hair, and sweat glands

What are the general recommendations for a venous insufficiency wound?

-limb protection

-risk reduction education

-inspect legs & feet daily

-compression to control edema

-elevate legs above the heart when resting/sleeping

-attempt active exercise including frequent ROM

-wear appropriate sized should with clean, seamless socks

What are clinical indicators of venous insufficiency wounds?

-localized limb pain; decreased with elevation & increased with standing

-pain with deep pressure or palpation

-pedal pulses present

-increased temperature around the wound

-indistinct, irregular edge

-edema around the wound

-shallow wound bed

-substantial drainage

What are pressure wounds/ulcers?

ischemia as a result of sustained pressure over weight-bearing bony prominences

With pressure wounds, how does tissue death occur?

initially internally and moves externally until it reaches surface

How do pressure wounds often happen?

low intensity and long duration or high intensity and short duration; friction and shearing forces contribute

Who are at high risk for pressure wounds?

bed/chair bound

What are common areas for pressure wounds in supine?

-back of head

-scapular spine

-spinous processes

-elbows

-sacrum

-heels

What are common areas for pressure wounds in sidelying?

-ear

-acromion

-ribs

-iliac crest

-greater trochanter

-med/lat condyle malleoli

What are the general recommendations for a decubitus/pressure ulcer?

-repositioning every two hours in bed

-management of excess moisture

-off leading with pressure relieving devices

-inspect skin daily for signs of pressure damage

-limit shear, traction, and friction forces over fragile skin

What are neuropathic ulcers?

on weight-bearing surfaces; associated with peripheral neuropathy and diabetes

What is the most common cause of LE amputation?

neuropathic ulcers

What is another name for neuropathic ulcers?

neurotropic or diabetic ulcers

What is another name for pressure wounds/ulcers?

decubitis ulcers

What is the best way to treat an ulcer?

prevent it

Long-term insulin use results in what?

decreased healing potential

What added problems do neuropathic ulcers have?

impaired sensation

What type of wound may lead to structural deformities causing increased pressure?

neuropathic ulcers

What are general recommendations for neuropathic ulcers?

-limb protection

-risk reduction education

-inspect legs & feet daily

-inspect footwear for debris prior to donning

-wear appropriately sized off-loading footwear with clean, cushioned, seamless socks

What are clinical indicators of neuropathic ulcers?

-painless ulcer

-general limb pain is present

-absent pedal pulse

-decrease temperature in distal limb

-deep wound bed frequently located at pressure points

-shiny skin on the distal limb

Peripheral neuropathy can significantly increase what?

risk of tissue damage

Why is monofilament testing used?

to assess protective sensation

Failure to perceive 10 gm monofilament indicates what?

loss of protective sensation

Failure to perceive 75 gm monofilament indicates what?

an area is insensate

What are chronic wounds?

wounds that exceed the expected length of recovery

How long does it take healthy wounds to heal?

3-6 weeks

When do chronic wounds occur?

when wound remains in one stage of healing without progression

What is a superficial wound?

epidermis only

What is a partial-thickness wound?

epidermis & superficial dermis

What is a full-thickness/subcutaneous wound?

to muscle, bone, and fat; dermis and subcutaneous tissue

What is the Wagner Ulcer Grade Classification Scale?

categorizes dysvascular ulcers based on wound depth and presence of infection

The Wagner Ulcer Grade Classification Scale most commonly used for?

diabetic ulcers

What is a 0 on the Wagner Ulcer Grade Classification Scale?

no open lesion; may have pre-ulcerative lesions; healed ulcers, deformity

What is a 1 on the Wagner Ulcer Grade Classification Scale?

superficial ulcer

What is a 2 on the Wagner Ulcer Grade Classification Scale?

deep ulcer into sub cut tissue

What is a 3 on the Wagner Ulcer Grade Classification Scale?

deep ulcer into osteitis or abscess