Wound Care: basics, pathophys

recalcitrant wound

wound that fails to respond to interventions after 2-4 wks despite multiple interventions

dermis

thick dense fibroelastic connective tissue that is highly vascularized

function: nourishment, protection, sensation, thermoregulation

includes: nerves, sweat glands, sebaceous glands, hair follicles

mast cells

use histamine and heparin to assist with blood clotting during injury

langerhans cells

1st line of defense against environmental antigens by capturing, uptake and processing antigens that stimulate an immune response

epidermis

provides a barrier against toxic substances and microorganisms, prevent water loss and repels water

includes: keratinocytes, melanocytes, langerhans cells, merkel cells

5 layers

thickness: 0.1 mm thick

acid mantle

acidic coating formed from sebum and sweat that delays growth of microorganisms on skin

if disrupted, skin is more prone to damage and infection

disruption occurs from: over washing, using alkaline soaps, exposure to incontinence or perspiration

stratum corneum

tightly lined cells of skin that protect against water loss

constitutive skin color

amount of melanin in the skin before exposure to UV radiation and hormones

facultative skin color

amount of melanin after exposure to UV radiation and hormones

why certain ethnic groups have darker skin

dermal layer is thicker and more compact + occur in higher amounts (higher number of thick collagen bundles below epidermis)

BMZ is 3 x longer

contains more fibroblasts that are larger- suggesting heightened activity possibly resulting in keloid and hypertrophic scar formation (African/Asain)

scarring is what percent higher in ethnic groups

15%

discuss with patients before scar inducing surgery or treatment

dyschromia

hypopigmentation or hyperpigmentation that occurs in skin next to other areas of the body

usually r/t cutaneous inflammation, injury, or dermatologic tx

hypopigmentation

usually resolves within weeks or months if primary cause is removed

effects can become permanent if melanocytes are completely destroyed

hyperpigmentation

might results as influence of inflammatory mediators and reactive oxygen species

macrophage

ingests dead tissue and cells

avascular

average 0.1 mm thickness

RBC fxn

to attract and move oxygen from lungs to bodys cells through hemoglobin

keratinocytes

produce keratin

desmosomes

bind keratinocytes together and provide strength to each layer of the skin as keratinocytes move to the surface

keratin

fibrous protein makes epidermis tough

most common WBCs

lymphocytes and neutrophils

fascia

white shiny sheath like covering for muscles, nerves, and blood vessels that keeps muscle fibers in tight bundles so they can act as a single unit

basement membrane

located between dermis and epidermis

flattens out w age

decreased surface area between skin layers- makes skin more susceptible to trauma

provides structure, facilitates exchange of fluid and cells between skin layers

extracellular matrix

largest component of dermis

provides structural support, regulates cellular functions, lubricates cells, provides transport system for nutrients and waste products

what causes dark skin to be thicker compared to lighter skin

presence of more compact collagen bundles in higher amounts and a longer basement membrane

dark skin inc risk of vit d deficiency because

increased melanin blocks effects of UV radiation- need more sun exposure for vit d synthesis

collagen

protein that gives skin tensile strength

fibroblast

develops connective tissue

produces collagen and elastin

elastin

protein gives skin elastic recoil

healthy muscle

pink-dark red, firm, highly vascular and striated

neutrophil

most common type of WBCs

attack and ingest microorganisms through phagocytosis

primary composition of pus

first responders

lymphocyte

recognize and produce antibodies to harmful microorganisms

SQ tissue

pale yellow, waxy, globular, oily substance that glistens

stores energy, supports blood vessels and nerves, cushions body, protects from cold

transepidermal water loss (TEWL)

amount of water lost through skin under nonsweating conditions

higher in darker skin which compromises the epidermal barrier function making skin more susceptible to irritants and possibly drier

ligaments

broader, flatter, more loosely woven than tendons

striations feel like tape with embedded threads

sebum

lipid rich oily substance secreted by sebaceous gland

acid mantle pH

4.0-6.8

avg 5.5

types of nerve receptors

pain, touch, temperature, itch, pressure

skin function

metabolism

exposure to UV B radiation from sunlight

cells in epidermis form vit d

results in maintenance of calcium and phosphorus levels in blood and bones

layer affected when a blister forms

BMZ

skin + aging

rete ridges flatten decreasing the surface area between the skin layers.

results in a reduction of nutrient transfer, decreased resistance to shearing forces, and impaired ability to retain water, all of which make the skin more vulnerable to trauma

fascia

white and shiny in appearance, (if gray= non viable)

sheath like covering for muscles, nerves, and blood vessels that keep muscle fibers in tight bundles so they can perform as single unit

muscles

pink to dark red, firm, highly vascular and striated,

granulation tissue must cover exposed _____ in a wound for healing to occur. Re-epithelialization over muscles not possible due to a lack of basal lamina to allow for epithelial cell migration.

ischemic muscle

mushy dull red, cyanotic or pale in color

necrotic muscle

turn to liquid causing a dark brown, odorous drainage

tendons

gleaming yellow or white, shiny strong fibrous tissue that attaches muscle to bone and springs back when touched

drying of exposed ______ occurs with the sheath often not surviving.

ligament

ribbon like striated pearly white CT that attaches bone to bone- seen in or near joints

Broader, flatter and more loosely woven than tendons and striations feel like tape with embedded threads

function to facilitate motion, limit motion, and add support

how many bones in the body

206

bones

contain 99% of bodys calcium and support/protect internal organs

shiny hard milky white appearance when healthy, slick to the touch

blood cells produced and stored in marrow

periosteum

outside layer surrounding most bones that consists of dense fibrous CT.

If break occurs it turns yellow or brown

bones will feel soft it this layer is intact, will feel rough if layer is absent

cartilage

thin layer of tough tissue covering the ends of bones where they meet the joint, allowing them to slide over one another while reducing friction and damage (shock aborber)

appear very white and shiny with poor vascular flow

same anatomic function as bone- so pressure injuries that have this exposed should be classified as stage 4***

RBC lifespan

120 days

then die and are removed by the spleen

lymphocytes

recognize and produce antibodies to harmful microorganisms that invade the body over a period of several days to weeks

holistic wound assessment

evaluating both systemic, local, psychosocial and other factors impacting wound healing

standard of care for skin assessment frequency

routine and systematic skin assessment upon admission

needs to be repeated on regular basis

pts at risk for pressure injury comprehensive skin assessments need to be done

as soon as possible after admission/transfer = within 8 hours

as part of every risk assessment

on a continuous basis depending on setting and level of risk

before discharging

most common cause of pressure injury in pediatric population

medical device related

lighting for skin assessment

use natural or halogen light

avoid fluorescent light

headlamps are excellent tool

non blancheable

visible skin redness that persists with application of pressure

indicates structural damage to the capillary bed

blanchable

visible skin redness that becomes white when pressure applied and reddens when pressure relieved

how to test blanch response

finger pressure method (3 seconds)

transparent disk method

use several measurement points for large areas of erythema

erythema in various skin tones

red or brown on light skin

black or purple in dark skin

pallor in various skin tones

white skin= loses its rosy tones

yellow tones= appears more yellow

black skin= loses red undertones appears ash gray

brown skin= becomes yellow tinges and looks dull

cyanosis various skin tones

light= skin lips and mucous membranes/ conjunctivae and nail beds appear blue tinged

dark= skin appears a shade darker. lips and mucous membranes appear pale or blue tinged. nail beds may have maroon tinge

carotenemia

yellow orange tint caused by increased levels of carotene in blood and skin

light skin= forehead, palms and soles

dark skin= palms and soles

*No yellowing of sclerae or mucous membranes

hemosiderin staining

dark pigmentation occurs from release of hemoglobin into extracellular space after hemorrhage

light skin= skin is reddish, rusty, brown or gray; may appear as ring wound pressure injuries or discoloration of skin of lower legs for venous disease

dark skin= discoloration or darker color present compared to surrounding

usually occurs near edges of wound

how to assess skin temp

back of the hand

non contact infrared thermometer

temp increase considered significant for inflammation

>2-3 F

warm skin can indicate

prescence of inflammation or chronic venous insufficiency

cool skin can indicate

decreased vascular supply

when assessing for edema

2 measurements taken: one of calf- one of ankle using measuring tape

calf/ankle measurements for edema

• measure at same location each time

• look for largest circumference of calf then mark the site on medial aspect of leg with a small dot using skin marker

• measure from the floor starting at 0 cm to the mark on the leg= floor to calf length\

• wrap tape measure around the calf at location of the mark to measure circumference

• measure from the floor starting at 0 cm to 5 cm above the medial malleolus. Mark site with small dot= floor to ankle length

• wrap tape measure around the ankle at the location of the mark to measure ankle circumference

assessing skin turgor

pinch skin near clavicle or forearm

*poor in older adults, dehydration, edema, or connective tissue disease

configuration

shape or outline of the lesion

ex: annular, circinate, iris, gyrate, linear, sperpiginous, margination, satellite, zosteriform

annular

round or circulat with central clearing

circinate

round circular arciform; partial circle

iris or target

series of concentric rings with a dark or blistered center

gyrate

connecting arcs

serpinginous

meandering; wander as though following the track of a snake

margination

sharp, ill defined

satellite

numerous red macules that surround the main lesion; often present in cutaneous candidiasis

zosteriform

dermatomal corresponding to nerve root distribution

distribution

clinical arrangement of lesions

ex: localized, generalized, symmetric, asymmetric, discrete, grouped, confluent, cleavage plane

localized distribution

grouped into specific areas

discrete distribution

separate

confluent distribution

aka coalescing

smaller into larger

cleavage plane distribution

arranged along lines of skin tension

morphology

form or structure of a lesion

ex: flat, raised, depressed, coloring, soft firm hard, fluctuant, sclerosed, hotter or colder, mobile or immobile

primary lesions

physical changes to skin- results of disease process and present at intial onset of problem

rarely specific to single disease

ex: vesicle, bulla, macule, patch, papule, nodule, pustule, wheal, plaque

vesicle

circular and fl filled

up to 1 cm

aka varicella and herpes zoster

bulla

circular, fl filled

greater than 1 cm

ex blister, pemphigus vulgaris

macule

circular, flat discoloration of skin (brown, blue, red, hypopigmented)

less than 1 cm

ex; freckle, flat mole (nevus), petechia, measles

patch

circular flat discoloration of skin (brown blue, red or hypopigmented)

greater than 1 cm

ex; vitiligo, port wine stain, mongolion spot, cafe au lait spot

papule

superficial solid elevated

less than 1 cm

color varies

ex wart (verruca), elevated mole, lichen planus

nodule

circular, elevated, solid

greater than 1 cm

may be above, level with or beneath skin surface

ex; erythema nodosum, lipoma

pustule

circular, elevated, collection of leukocytes

free fl filled

varies in size

ex; acne, impetigo

wheal

firm, elevated, edematous plaque

irregular shaped area of cutaneous edema

infiltration of dermis, transient, may last a few jours

ex insect bite, allergic reaction, TB skin test

plaque

superficial elevated, solid, flat topped lesion

firm rough greater than 1 cm

ex psoriasis, seborrheic keratosis, actinic keratosis

secondary lesions

occur from primary lesions or external forces such as scratching, trauma, infection and the healing process

ex: scale, crust, fissure, erosion, ulcer, lichenification, atrophy, scar, excoriation

scale

flakes or plates that build up on the skin from an increase in dead cells on skins surface

irregular, thick or thin, dry or oily

variable size

ex= seborrhic dermatitis, dry skin, dandruff

crust

drying of plasta or exudate on the skin

slightly elevated

varies in size and color

ex scab, eczema