NPTE - Integumentary

During assessment of skin sensation, which of the following structures

are responsible for transmission of pressure and vibration sensation?

A. Meissner corpuscles

B. Krause end bulbs

C. Pacinian corpuscles

D. Ruffini endings

C (Pacinian corpuscles are seen with pressure and vibration - Pressure = Pacinian (+ vibration), Meissner = light tough and textures (me ; i like light touch and nice textures, Krause End bulbs (kraus is cold), Ruffini Endings = stretch and warmth (rufus the naked mole rate likes to stretch and is warm)

Image of mouth with cold sores around lips

A patient arrived at a clinic with a skin disorder

as shown in the image. Which of the following is

the MOST APPROPRIATE diagnosis and

precaution to be taken?

A. Herpes simplex virus type 1,

contact precautions

B. Herpes zoster, airborne precautions

C. Dermatitis, contact precautions

D. Herpes simplex virus type 2,

contact precautions

A (Herpes simplex type 1 = above the waist line and we utilize contact precautions, herpes zoster is in the dermatomal pattern, herpes type 2 is below the waist line; it is also known as genital herpes)

A patient presents with a wound on their right lower

extremity and has a history of painful cramping in the

legs, especially after walking for a few minutes.

Medical history is significant for diabetes type II and

hypertension. Which of the following would BEST

describe the characteristic of this wound?

A. Wound located on the dorsum of toes, base of the

wound is pale and necrotic with lack of granulation

tissue

B. Wound located on the dorsum of the foot, hemosiderin

staining present along with fibrosis of dermis

C. Wound located on the medial malleolus with swelling of

bilateral lower extremities that is relieved with rest

D. Pitting edema in the lower extremities, numbness and

tingling along with hyperkeratosis of the skin

A (they are describing arterial insufficiency/intermittent claudication, the dorsum of the toes as well as pale wound is common in arterial insufficiency wounds option B-C is describing venous insufficiency, D is referring to lymphedema)

T or F: If a pressure ulcer is originally stage 3, but heals and no longer is seen with fat etc., we can re-stage it as a stage 2

False (stages of pressure ulcers can never be backstaged; you can document the progress of it, but you keep the original stage at diagnosis)

A physical therapist is treating a patient, who was originally diagnosed

with a pressure injury stage 3. The patient presents to the clinic with

ulcer shown in the picture. Which of the following is true?

A. The pressure injury is now an unstageable ulcer

B. The pressure ulcer is now a stage 1 ulcer

C. The pressure ulcer is now a stage 2 ulcer

D. A pressure ulcer can not be back-staged

D (the stage cannot be back staged, therefore it is still a stage 3, but can improve. If things get worse, the stage can increase, just not backstaged)

Ulcer located on the medial aspect of

the ankle.

Venous Ulcer

Ulcer located on weight bearing

surfaces.

Diabetic Ulcer

Ulcer that is well-defined and shiny.

Arterial Ulcer

Ulcer that is caused from unrelieved

external pressure.

Pressure Ulcer

A patient develops a stage 2 pressure injury over the sacrum and is

referred to physical therapy for wound care. Which of the following is

the MOST APPROPRIATE initial application to clean the wound?

A. Povidone-iodine solution

B. Sterile normal saline

C. Zinc oxide cream

D. Nitrofurazone solution

B (the first appropriate application is saline solution, and it is just a stage 2 pressure ulcer which can be addressed with this. The remaining options are a bit too aggressive; Povidone-iodine is for infection at a surgical site, Zinc oxide cream is used for dental fillings, Nitrofurazone is for burns and skin grafts)

A patient has a deep partial-thickness wound with 70% necrosis and

30% granulation tissue. Which of the following is MOST APPROPRIATE

wound care option?

A. Wet to dry dressings

B. Autolytic debridement

C. Enzymatic debridement

D. Biological debridement

A (wet to dry is seen in non-selective debridement; which we choose because necrosis >50% indicates non-selective. the remaining; autolytic debridement and enzymatic debridement is associated with selective removal; which we cannot choose as there is 70% (>50% non-viable tissue))

A patient has a grade III pressure ulcer. The wound has excessive

amounts of exudate present. Which of the following is the MOST

APPROPRIATE dressing to use?

A. Hydrofiber dressing

B. Hydrocolloid dressing

C. Hydrogel dressing

D. Transparent film

A (for excessive amounts of exudate; we utilize hydrofiber or calcium alginates, a foam would be utilized with moderate exudate, hydrocolloid is minimal exudate; along with the hydrogel, transparent film is used for the complete opposite; dry/slight to no exudate)

Case Study: Patient in MVA burned on anterior right arm, anterior right leg, anterior chest and abdomen, no burns of L side of body. Burn is waxy white, capillary refill delayed pain felt with deep pressure to wound, reduced chest mobility, scar formation.

Which type of burn does this

patient have?

A. Superficial burn

B. Superficial partial-thickness

burn

C. Deep partial thickness burn

D. Subdermal burn

C

Case Study: Patient in MVA burned on anterior right arm, anterior right leg, anterior chest and abdomen, no burns of L side of body. Burn is waxy white, capillary refill delayed pain felt with deep pressure to wound, reduced chest mobility, scar formation.

Which of the following BEST

represents the percentage of body

surface area involved?

A. 31.5%

B. 18%

C. 36.5%

D. 45%

A (anterior trunk 18, anterior R LE 9, anterior R UE 4.5 = 31.5%)

What is the largest organ of the body?

Skin (15-20% of bodyweight)

Meissner Corpuscle

Touch (fine touch, discriminative touch & vibration)

-light touch and texture detection

(ME= I touch MEself)

Krause End Bulbs

detects cold (a cold Santa Kraus)

Pacinian Corpuscles

Pressure and vibration (P for Pacinian and pressure/vibration)

Ruffini Endings

Stretch and warmth (Rufus the naked mole rat stretches and is warm)

Free Nerve Endings

Pain, temperature, touch, pressure, tickle, itch (we know, all the sensations/peripheral sensations)

Herpes Zoster - Shingles

Rash in a dermatomal pattern w/ pain and paresthesia (unilateral)

-fluid-filled, raised, white, and pink

Contagious Precautions for Herpes Zoster/Shingles

Contact precautions + airborne

CNs impacted in Herpes Zoster/Shingles

CN3 - Oculomotor (moving eyes vertically)

CN5- Trigeminal (chewing)

(CN7 and CN10 as well, but not as common/dont need to focus)

Pain management of Herpes Zoster/Shingles

TENS

Herpes Simplex Virus Type 1

above the waist; on the mouth

Herpes Simplex Virus Type 2

below the waist; genital herpes

Precautions for Herpes Simplex for both types

Contact precautions

Venous Insufficiency Wounds

-wet wound

Skin: brownish discoloration, hemosiderin staining

Location: medial malleolus (VENMO=venous insuff, medial malleli)

Borders: irregular shape, shallow appearance

-mild to moderate pain; elevation decreases pain

Arterial Insufficiency Wounds

Skin: dry, shiny skin, hair loss, yellow nails

Borders: smooth edges, well defined, tends to be deep

Location: Toe, dorsum of foot, lateral malleolus (ALMA - arterial lateral mall)

-severe pain

-intermittent claudication can cause

-elevation will increase the pain

Intermittent Claudication

Muscle cramping after and with movement (understand this is not a DVT)

-we want to avoid elevation and utilize gravity

Example of Intermittent Claudication Intervention

intermittent walking, and stopping right before the pain increases

Scale of Intermittent Claudication - grade 1

discomfort

Scale of Intermittent Claudication - grade 2

moderate discomfort - can be distracted from it

Scale of Intermittent Claudication - grade 3

intense pain, cannot be distracted

Scale of Intermittent Claudication - grade 4

unbearable

Pressure Ulcers

Occur over bony areas

(the stages are related ot the depth of the wound bed)

Stage 1 Pressure Ulcer

redness of the skin; nonblanchable (but skin is intact)

Stage 2 Pressure Ulcer

Superficial pink/red shallow crater

-epidermis/partial thickness

Stage 3 Pressure Ulcer

3 = fat (fat has 3 letters)

-fat appears white, slough/eschar, undermining/tunneling can occur

(full thickness)

Stage 4 Pressure Ulcer

bone (4 letters = bone)

Bone, tendon, muscle, slough/eschar, often undermining/tunneling

Unstageable Pressure Ulcer

wound completely covered in slough/eschar = depth unknown

Deep Tissue Injury

Skin intact, but purple (deep bruise)

Slough

moist, yellow, brown

Eschar

Dry, hard, black or brown

T or F: Even if you see a wound heal through the stay; pressure ulcers cannot be back staged

True (but if it gets worse; it can be restaged)

Wound Measurement

height x width x depth; measured in centimeters

(use disposable ruler, depth can be measured by cotton swab)

Wound Characteristics

granulation - viable tissue

necrotic tissue - non viable

Indurated Wound

Hard, firm tissue around the wound

-May signal inflammation or infection

Epibole Wound

Rolled-under wound edges

-impair wound healing

Transudate Drainage

clear, thin, watery - normal

Serosanguineous Drainage

clear, slight red/brown, normal and indicates wound healing

Serous Drainage

clear, amber, thin, watery - Normal

Sanguineous Drainage

Abnormal

bright bloody; indicates inflamed wound

Pus Drainage

Abnormal

yellow, brown, mod to very thick

Infected Pus

Abnormal

yellow, blue, green, thick foul smell

-often indicates infection

Maceration

(M for moist)

Too moist, wrinkled white skin

(from inappropriate wound care, wound drainage, perspiration, incontine

Desiccation

(D for dry)

Too dry, cracking, flakey edges, hard

(from incorrect wound care, infection or dehydration)

Selective Debridement

Removal of only non-viable tissue from a wound

-sharp, enzymatic, autolytic

Types of Selective Debridement

Sharp, enzymatic autolytic

Sharp Debridement

Selective

scalpel, scissors or forceps

Enzymatic Debridement

Selective

-topical application of enzymes

Autolytic Debridement

Selective

using body's mechanisms to remove non-viable tissue

Nonselective Debridement

Removal of both nonviable and viable tissue from the wound

When is Non-Selective Debridement warranted?

If >50% of the wound is non-viable tissue

Types of Non-Selective Debridement

Wet to Dry Dressings

Wound Irrigation

Hydrotherapy

Wet to Dry Dressing Debridement

Non-selective

moist gauze on necrotic tissue; completely dries then removed

Wound Irrigation Debridement

Non-selective

moves necrotic tissue with pressurized fluid

Hydrotherapy Debridement

Non-Selective

-whirlpool

Dressing for slight to no Exudate (dry)

Transparent Film

Dressing for minimal Exudate (dry)

Hydrogel, Hydrocolloid

Dressing for Moderate Exudate

Foams

Dressing for Heavy Exudate (wet)

Calcium alginate, hydrofiber

Dressing Utilized for Infected Wounds

Hydrogel, Calcium alginate, Hydrofiber

Red seen in a Wound

granulation = good

-keep moist and clean

Dressing for granulation in wound

transparent film or potential hydrogel, hydrocolloid

Yellow seen in a wound

infection

-clean and remove yellow layer

Dressing for Yellow in a wound

(after removing yellow)

-Hydrogel, foam, moist gauze (moisture retentive)

Black seen in wound; Dressing choice

Debride sharp, enzymes, keep clean and dry

For wounds with inadequate blood supply and non-infected heel ulcers,

Don't debride. Keep them clean and dry.

Rules of Nine Burns : Head

1x (9%)

Rules of Nine Burns: Chest

2x (18%)

Rules of Nine Burns : Back

2x (18%)

Rules of Nine Burns : Left Arm

1x (4.5% ant, 4.5% post)

Rules of Nine Burns : Right Arm

1x (4.5% ant, 4.5% post)

Rules of Nine Burns : Left Leg

2x (4.5% ante/sup, 4.5% ante/dist, 4.5% post/sup, 4.5% post/dist)

Rules of Nine Burns : Right Leg

2x (4.5% ante/sup, 4.5% ante/dist, 4.5% post/sup, 4.5% post/dist)

Rules of Nine Burns : Perinium

1%

Superficial Burn

redness of the skin, blanchable

-heals in ~1 week, no scarring

Superficial Partial Thickness Burn

extremely painful

mottled red, weaping blisters, blanches w quick capillary refill

-heals 2 weeks; min scarring

Deep Partial Thickness Burn

Mixed red & whites, decreased pinprick sensation

-blanches w slow capillary refill

-3 wks to heal; could be managed surgically

Full Partial Thickness

Dry, leathery eschar

-lacks pain, pressure, and temperature sensations

-must be surgically managed, potential contractures

->3 weeks to heal

Subdermal Burn

Exposed deep tissue, charred & dry

-surgical intervention; potential amputation & paralysis

A Normal Scar

flat and similar to skin color

Hypertrophic Scar

thick & fibrous; but within the wound border

Keloid Scar

outside of margins of the wound; excessive scar tissue

Rule of 9s - Children - Head

18% (total; including front & back, 2x9)

Rule of 9s - Children - Arm

9% (total) (same as adults)

Rule of 9s - Children - Leg

14% (for each)

Rule of 9s - Children - Front Torso

18% (2x) (same as adult)

Rule of 9s - Children - Back Torso

18% (2x) (same as adults)