PT Final Exam NPTE: Integumentary System

dermis

High mechanical strength

•Low stiffness (resistance to deflection)

•Highly vascular

•Thermoregulation

•Skin nutrition

•Inflammatory response

free nerve endings

dermis sensory

pain/itch

merkel's disc

dermis sensory

touch/pressure

ruffini/krause

dermis sensory

temperature

meissner/pacinian

dermis sensory

vibration

chemical burn

keeps burning until neutralized (acids, bases, caustic agents)

superficial burn

Superficial, redness, hot to touch, no blisters

superficial partial thickness burn

Skin is mostly intact, most of the basal layer is intact

•Blisters, redness, very painful

deep partial thickness burn

burn: Extends >50% through dermis

•Yellow/white, some blisters

full thickness burn

White/brown/blackish, painless, dry

1st degree

superficial burn

2nd degree

partial thickness burn

3rd degree

full thickness burn

stage 1

pressure ulcer: nonblancheable erythema

stage 2

pressure ulcer: partial thickness skin loss

stage 3

pressure ulcer: full thickness to underlying fascia

stage 4

pressure ulcer: full thickness to bone, tendon, or muscle

unstageable

pressure ulcer: covered thickly in eschar or adherent slough

braden scale

scale for pressure ulcer risk, total 23

15-16

braden: low risk for pressure ulcer

13-14

braden: moderate risk for pressure ulcer

<12

braden: high risk for pressure ulcer

arterial insufficiency

Decreased blood supply

•Punched out, even edges

•Linked to atherosclerosis, claudication

arterial insufficiency

Loss of hair, cyanotic, pale, ashen

•Linked to diabetes, hypertension, hyperlipidemia, smoking

•Painful

arterial insufficiency

Minimal drainage

•Absent or decreased pulse, Low ABI <.08

•Rubor of dependency

venous insufficiency

Decreased blood return

•Large, irregular edges

•Shallow depth, inflamed surrounding skin

venous insufficiency

Edema, indurated, hyperpigmented, hemosiderin staining, red

•Usually above the malleoli,

•Usually minimal pain, decreased with elevation

venous insufficiency

Moderate to maximal drainage

•High ABI >.08

ABI

Ratio of: (highest ankle blood pressure) /(highest brachial pressure)

arterial insufficiency

Nutrition

•Revascularization

•Control modifiable risk factors

•Moist/optimal wound environment

•Occlusive dressing

•Debridement

•Protect and prevent with good footwear and regular inspections

venous insufficiency

Nutrition

•Compression, Unna Boot,

•Control modifiable risk factors

•Control exudate

•Highly absorptive dressing, multi-layer

•Debridement

•Protect and prevent with good footwear and regular inspections

wagner

scale for diabetic wounds

0

wagner: thick calluses, bone deformities, clawed toes, prominent metatarsian head

foot at risk

1

wager: total destruction of thickness of skin

superficial ulcers

2

wagner: penetrates through skin, fat, and ligaments, but not affected bone

infected

deep ulcers

3

wagner: limited necrosis in toes or the foot

abscessed deep ulcer

4

wagner: limited necrosis in toes or foot

limited gangrene

5

wagner: necrosis of complete foot with systemic effects

extensive gangrene

autolytic debridement

seal it in and let Mother Nature do her work

mechanical debridement

Wound scrubbing, wet-to-dry, whirlpool, pulsatile lavage, ultrasound

infected wound

splotchy, expansive, striped redness

systemic fever

strong odor

mod/max exudate

infected wound

serous or purulent exudate

persistent pain

surrounding tissue indurated, accompanied by increased temperature

inflamed wound

well defined borders redness

localized temperature increased

weak odor

minimal exudate

inflamed wound

sanguinous exudate

variable pain

slight to minimal firmness

calcium alginate

very absorptive

foam dressing

absorptive and comes with borders

transparent film

no absorption, easily monitored, seal it in

hydrogel

water and glycerin, used in dryer wounds

hydrocolloid

occlusive bandage, but some absorption

gauze

absorptive, but non-wicking

impregnated gauze

petrolatum or iodine

hydrofibers

most absorptive (Aquacell)

9%

head and neck

18%

anterior trunk

18%

posterior trunk

9%

B anterior UE

9%

B posterior UE

1%

genitals

18%

B anterior LE

18%

B posterior LE

pseudomonas infection

Sweet odor, especially if accompanied by thin, foamy, green drainage, a "ripe" or "fruity" odor

clostridium

Strong pungent odor along with tissue necrosis or separation of skin into paper thin blackpurple layers

putrescine

Pungent-swelling known to elicit the gag reflex & can cause vomiting, a rotten smell

examine for tunnelling

Rimming or undermining. Underlying tissue destruction beneath intact skin. Sinus tracts: communication with deeper structures; associated with unusual or irregular borders Clock Concept: 12 O'clock is the direction of patient's head and 6 o'clock is toward the feet. Name undermining for direction of deepest tunnel

girth

Use circumferential measurements of both involved and noninvolved limbs; referenced to bony landmarks Use volumetric measurements: measure water displacement from filled volumeter. Reliable and valid for girth (edema) but unreliable for wound volume measurement

viability of periwound tissue

Halo of erythema, warmth, and swelling may indicate infection Maceration of surrounding tissue due to moisture (urine, feces) or wound drainage increases risk for wound deterioration and enlargement Trophic changes may indicate poor arterial nutrition Cyanosis may indicate arterial insufficiency

zone of coagulation

burn: cells are irreversibly injured, cell death occurs

zone of stasis

cells are injured; may die without specialized treatment (24-48 hours)

zone of hyperemia

minimal cell injury; cells should recover

avulsion

aka degloving, is a serious wound resulting from tension that causes skin to become detached from underlying structures

laceration

a wound or irregular tear of tissues often associated with trauma. Result from shear, tension, high force compression with the resultant would characteristics dependent on MOI

penetrating

results from various MOIs and is described as a wound that enters the interior of an organ or cavity

puncture

made by a sharp pointed object as it penetrates the skin and underlying tissue. Relatively little tissue damage beyond the wound tract, risks of contamination and infection can be significant

skin tear

results from trauma to fragile skin such as bumping into an object, adhesive removal, shear or friction forces. Can range from a flap-like tear, that may or may not remain viable, to full thickness tissue loss

superficial wound

Causes trauma to skin with the epidermis remaining intact, such as a non-blistering sunburn

Heal as part of the inflammatory process

partial thickness wound

Extend through the epidermis and possibly into, but not through, the dermis.

Heal by re-epithelialization or epidermal resurfacing depending on depth

full thickness wound

Extend through the dermis into deeper structures such as subcutaneous fat, considered full thickness if deeper than 4mm

Heal by secondary intention

subcutaneous wound

Extend through integumentary tissue and involve deeper structures such as subcutaneous fat, muscle, tendon, bone

Heal by secondary intention

dermatitis

inflammation of the skin that includes crusty, dry patches, itching, oozing, dryness, and rashes. Eczema is also part of this, though it too refers to a broad range of conditions. Causes can include poison ivy, allergic reactions to soaps/chemicals/plants, photosensitivity, etc.

acute dermatitis

red, oozing, crusting, rash, extensive erosions, exudate pruritic vesicles

subacute dermatitis

erythematous skin, scaling, scattered plaques

chronic dermatitis

thickened skin, increased skin marking 2/2 scratching; fibrotic papules and nodules; post inflammatory pigmentation changes