Integumentary/ Burn splinting/ Skin conditions

Layers of skin

• Epidermis (B KLM)

  • keratinocytes, melanocytes, langerhans cells, basal cells

• Dermis

  • collagen, reticulum, fibroblasts, macrophages, lymphatic glands, blood vessels, nerve fibers

Skin receptors and function- Meissner’s corpuscles

• detect light touch and texture (MeLT)

Skin receptors and function- Merkel Disks

• Detect light tough, texture, and pressure

Skin receptors and function- pacinian corpuscles

• Detect deep pressure and vibration

Skin receptors and function- Ruffini endings

• Detect warmth, stretch deformation within joints

Skin receptors and function- Free nerve endings

• Detect pain, temperature, touch, pressure, tickle and itch

Skin receptors and function- krause end bulbs

• detect cold temperature

Pressure Ulcers- General

• Pressure wounds are located over bony pressure areas and are staged related to the depth of the wound bed

• Occur due to immobility

• A pressure injury CAN NOT BE BACKSTAGED

Pressure Ulcers- Stages

• Deep tissue injury- intact skin, purple maroon appearance

• Stage 1- intact skin with non-blancable redness

• Stage 2- partial thickness wound, superficial in nature with pink/ red wound bed (shallow)

• Stage 3- full thickness wound, subcutaneous fat tissue visible but no bone, tendon, or muscle exposed (deep)

  • slough/ eschar present, undermining and tunneling may occur

• Stage 4- full thickness with exposed bone, tendon, or muscle

  • slough/ eschar present, undermining and tunneling often occur

• Unstageable- wound bed covered with slough/ eschar (unable to identify the depth)

Pressure injury- interventions

• Positioning and pressure redistribution devices

  • Bed- every 2 hours

  • W/C- every 15 min

  • Frail patients- every 30 min

• Elevate heels and keep the head of the bed <30 degrees unless necessary

• avoid WB on bony prominence/ wounds

• Air-filled cushions reduce pressure and friction while sitting

• educate patients/ caregivers on pressure relief strategies

Arterial wounds/ insufficiency

• Arterial insufficiency- Refers to a lack of adequate blood flow to a region of the body

• Arterial wounds:

  • Location: Toes, lateral malleolus, heels, anterior shins

  • Drainage: Minimal Arterial insufficiency- Refers to a lack of adequate blood flow to a region of the body

  • Arterial wounds:

    • Location: Toes, lateral malleolus, heels, anterior shins

    • Drainage: Minimal to slight exudate (usually dry)

    • Wound margins: Discrete punched out

    • Wound appearance: pale

    • Edema: none

    • Odor: none

    • Pain: likely (ischemic) Arterial insufficiency- Refers to a lack of adequate blood flow to a region of the body

Venous wounds/ insufficiency

• Venous insufficiency- Refers to inadequate drainage of venous blood from a body part, usually resulting in edema and/or skin abnormalities and ulcerations

• Venous wounds:

  • Location: Near medial/ lateral malleolus, above malleoli, below knee

  • Drainage: moderate to heavy exudate

  • Wound margins: irregular borders

  • Wound appearance: hyperpigmentation (hemosiderin staining)

  • Edema: likely

  • Odor: strong

  • Pain: none

Interventions- Arterial disorders

• Best: supervised interval walking (ischemic pain)

• Positioning: legs down (dependent)

• Education: smoking cessation; diabetes/ lipid/ BP control

• Contraindication: Compression if ABI is abnormal; cold; vigorous massage

Interventions- Venous Disorders (CVI/ Venous Ulcers)

• Best: Compression therapy (walk with compression garments)

• Positioning: Elevation

• Education: Avoid prolonged sitting/ standing; encourage movement

• Contraindication: Heat on edematous limbs; prolonged dependent positioning; high-impact exercise with active ulcer

Wagner scale- Diabetic wound classification

• Grade 0: No open lesions. The skin is intact, though the foot is "at risk" due to bony deformities, pre-ulcerative lesions, or cellulitis.

• Grade 1: Superficial ulcer. Involves a partial- or full-thickness ulcer without penetration into the deeper layers or exposure of subcutaneous tissue.

• Grade 2: Deep ulcer. The ulcer penetrates deeply, reaching the tendon, ligament, joint capsule, or deep fascia, but there is no abscess or bone infection.

• Grade 3: Deep abscess, osteomyelitis (bone infection), or joint sepsis.

• Grade 4: Partial-foot gangrene affecting the toes or forefoot.

• Grade 5: Extensive gangrene affecting the entire foot.

Key points to remember- Different types of wounds

• Diabetic ulcers- generally located on the WB surface of the foot

• Venous insufficiency- frequently are proximal to the medial malleolus. they are edematous

• Arterial ulcers- generally located on lateral malleolus, distal toes, or areas of trauma

• Pressure ulcers- result of unrelieved external pressure on an area

Burn- Epidermal

• Vascularity: intact

• Color: Erythematous, pink/ red

• Surface appearance/ pain: delayed pain; tenderness

• Swelling/ healing/ scarring: minimal edema, heals spontaneously

Burns- Superficial partial thickness

• Vascularity: Blanching with brisk capillary refill

• Color: Bright pink/ red

• Surface appearance/ pain: very painful

• Swelling/ healing/ scarring: moderate edema; heals spontaneously, minimal scarring

Burns- Deep partial thickness

• Vascularity: Blanching with slow capillary refill

• Color: Mixed red and waxy white

• Surface appearance/ pain: Sensitive to pressure, but insensitive to light touch/ pinprick

• Swelling/ healing/ scarring: marked edema, slow healing, scarring

Burns- Full-thickness

• Vascularity: no blanching

• Color: white (ischemic)

• Surface appearance/ pain: Anesthetic; body hairs pull out easily

• Swelling/ healing/ scarring: Area depressed, requires skin grafting; scarring +

Burns- Subdermal

• Vascularity: none

• Color: Charred

• Surface appearance/ pain: Anesthetic, muscle, and nerve damage present

• Swelling/ healing/ scarring: Tissue loss, heals with skin graft or flap, scarring +

Rule of 9’s- Adult

• Head (A): 4.5

• Arm (A): 4.5

• Leg (A): 9

• Torso (A): 18

• Perineum: 1

Rule of 9’s- Child

• Head (A): 8.5

• Arm (A): 4.5

• Leg (A): 6.5

• Torso (A): 18

• Perineum: 1

Scars

• Normal: Flat and similar to skin color

• Hypertrophic scar: a healed wound with thick fibrous tissue that remains within the original wound border

• Keloid: condition which excessive scar tissue grows outside of the original margins of the wound

Types of wound drainage

• Transudate- clear, thin, and watery

• Serous- clear/ amber, thin and watery

• Serosanguineous- Clear/ tinge of red/ brown, thin and watery

  • indicates a wound is healing

• Sanguineous- Bloody, bright red fluid, indicates inflamed wound

• Pus- yellow/ brown, moderate to very thick

• Infected pus- hues of yellow, blue, and green, thick, and usually indicates infection, drainage may be foul

  • may not indicate infection as WBC macrophage necrotic tissue

Maceration

• wound is too moist, edges and periwound will become macerated

  • identified as white, friable, overly hydrated, and sometimes wrinkled skin

  • Cause: inappropriate wound care, uncontrolled wound drainage, perspiration, or incontinence

Desiccation

• If a wound lacks moisture, the wound and periwound will become desiccated

  • It is identified as cracked, with dry or flaky edges, and the tissue within the wound bed may be hard or crusty

  • Cuase: inappropriate wound care, inadequate moisture, infection, dehydration

Debridement- Selective

• Removal of only nonviable tissues from a wound

• Sharp debridement- use of scalpel, scissors, forceps (precise removal)

• Enzymatic debridement- use of a topical application of enzymes (collagenase)

• Autolytic debridement- Use of the body’s own mechanisms to remove nonviable tissue

• Biologic (maggot therapy)- Sterile larvae digest necrotic tissue

Blue SEA

Debridement- Nonselective

• Removal of both non-viable and viable tissues from a wound

  • > 50% dead tissue

• Wet to dry dressing- application of a moistened gauze over area of necrotic tissue to be completely dried and removed

• Wound irrigation- moves necrotic tissue from wound bed using pressurized fluid

• Hydrotherapy: using a whirlpool with agitation directed toward a wound requiring debridement

Dressings

• Based on exudate and if the wound is infected

• Heavy exudate: calcium alginates, hydrofibers

• Moderate exudate: foams

• Minimal exudate: hydrogel dressing, hydrocolloid

• Very mild exudate: transparent films

• Infected wounds: hydrofiber, hydrogels, calcium alginates, and gauze

  • NO HYDROCOLLOIDS IN INFECTED WOUNDS

Neck

• Normal: flexion contracture

• Stress hyperextension

  • firm cervical orthosis

Shoulder

• Normal: adduction/ internal rotation contracture

• Stress abduction and flexion or external rotation

  • axillary splint or air splint

Elbow

• Normal: flexion or pronation contracture

• Stress extension or supination

  • splint

Hand

• Normal: most likely claw hand deformity

• Stress wrist extension, metacarpophalangeal (MCP) flexion, proximal interphalangeal (PIP) and distal interphalangeal (DIP) extension, thumb abduction

Hip

• Normal: flexion or adduction contracture

• Stress hip extension or abduction

Knee

• Normal: flexion contracture

• stress extension after splint

Ankle

• Normal: plantar flexion contracture

• Stress dorsiflexion

Herpes Zoster (viral)

• Dermatomes- Herpes zoster (shingles) has initial symptoms of pain and paresthesia localized to the affected dermatome

• Presents as a painful rash with clusters of fluid-filled vesicles

• Mostly unilateral

• Raised to palpation (<2mm height)

• Pink with silvery white appearance

• CN 5 and 7 most affected

• Viral- contact precautions

  • airborne + contact precautions when condition becomes disseminated/ spread/ patients with weakened immune systems

Herpes Simplex

• HSV-1 (Type 1)- primarily causes oral lesions (cold sores, fever blisters)

  • Spread through saliva; lies dormant in the trigeminal ganglion

  • Recurs with stress, sunlight, or illness

• HSV-2 (Type 2)- Primarily causes genital herpes with more frequent recurrences

  • Spread through sexual contact; dormant in sacral ganglia

  • higher risk for neonatal transmission during childbirth

Kaposi’s Sarcoma

• Etiology: viral, caused by human herpes virus-8 (HHV-8)

• Common in: immunocompromised patients, especially those with HIV/ AIDS

• Appearance: Multiple red, purple, or brown macules, plaques or nodules often on skin, mucous membrane, or internal organs

• DOES NOT SPREAD THROUGH CONTACT

Cellulitis

• Bacterial skin infection of the dermis/ subcutaneous tissue (strep/staph)

• Presents with redness, warmth, swelling, tenderness

• often unilateral; associated with breaks in skin, edema, diabetes

• requires systemic antibiotics; elevate limb

• PT: no massage or compression during acute stage

• RED FLAGS: rapidly spreading redness, fever, systemic s/s

Skin Cancer ABC’s

• A- Asymmetry- one half is unlike the other

• B-Border- blurry and/or jagged edges

• C-Color- more than one shade or color

• D-Diameter- greater than 6mm

• E-Evolution- watch for changes over time. If your mole changes in size, shape or color it might be suspicious