FF - integ

What does the epidermis consist of?

keratinocytes, melanocytes, Langerhans cells, basal cells

What does the dermis consist of?

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

What are the skin receptors?

• Meissner corpuscles

• Merkel discs

• Pacinian corpuscles

• Ruffini endings

• free nerve endings

• Krause end bulbs

What do the Meissner corpuscles detect?

light touch & texture

What do the Merkel discs detect?

light touch, texture, pressure

What do the Pacinian corpuscles detect?

deep pressure & vibration

What do the Ruffini endings detect?

warmth, stretch, deformation within joints

What do the free nerve endings detect?

pain, temp, touch, pressure, tickle, itch

What do the Krause end bulbs detect?

cold

What are the stages of pressure ulcers?

• deep tissue injury (DTI): intact skin, purple/maroon

• stage 1: intact skin, non-blanchable redness

• stage 2: partial thickness, superficial, pink/red

• stage 3: full thickness, down to fat layer, SETU

• stage 4: full thickness, down to bone/tendon/mm, SETU

• unstageable: wound bed covered by slough/eschar (often stage 3 or 4)

What are the interventions to prevent pressure ulcers?

• positioning & pressure redistribution

• turning every 30 min or every 4 hrs

• elevate heels, keep HOB <30°

• avoid WB of greater trochanter or on existing wounds

• avoid donut cushions, use pillows/wedges to separate bony areas

• air-filled cushions reduce pressure & friction while sitting

Describe arterial ulcers

• caused by arterial insufficiency

• typically found on toes, lateral malleolus, heels, anterior shins

• minimal to no exudate

• discrete punch out

• pale, no edema, odorless, painful (intermittent claudication)

What are some interventions for PAD?

• supervised interval walking

• education on smoking cessation, diabetes/lipid/BP control

• contraindications: elevation, compression if ABI <0.8; cryotherapy; vigorous massage

Besides elevation, what else should you avoid with arterial ulcers?

heat pads and soaking feet in hot water

Describe venous ulcers

• caused by venous insufficiency

• typically found on medial side of shin

• moderate to heavy exudate

• irregular borders

• hemosiderin staining (hyperpigmentation), edema, strong odor, painless

What are some interventions for venous ulcers?

• elevation

• compression

• encourage movement

• contraindications: heat on edematous limbs; prolonged dependent positioning (sitting/standing); high-impact exercise w/ active ulcer

What should pts with diabetic neuropathy avoid?

avoid lotion b/w their toes

What tool is used to test for protective sensation?

Semmes-Weinstein monofilament

• if pt can feel 4.17 monofilament → normal sensation (healthy)

• if pt can feel 5.07 monofilament (10g) → protective sensation (foot can detect injury)

Describe the stages of burns

• epidermal: pink/red, intact vascularity, delayed pain or tenderness, minimal edema, heals spontaneously (sunburn)

• superficial partial thickness (upper dermis): bright pink/red, blanching w/ brisk capillary refill (blood vessels intact), very painful, moderate edema, heals spontaneously, minimal scarring

• deep partial thickness (most of dermis): mixed red & white, blanching w/ slow capillary refill (some blood vessels destroyed), sensitive to deep pressure (not LT/PP), marked edema, slow healing, scarring

• full thickness (all of dermis): white (ischemic), no blanching, no pain, area depressed, scarring, requires skin grafting

• subdermal (hypodermis): charred, no pain, mm & nerve damage present, tissue loss, scarring, requires skin grafting

What are the different types of scars?

• atrophic scars

• hypertrophic scars

• keloid scars

What are atrophic scars?

sunken & often hyperpigmented scars d/t loss of collagen

What are hypertrophic scars?

healed wound w/ thick fibrous tissue that remains within the original wound border

What are keloid scars?

excessive scar tissue that grows outside the original margins of the wound

Describe the Rule of 9’s for estimating % total body surface area burned in adults & children

adults — children/infants

• torso = 18%

• leg = 9% — 6.5%

• arm = 4.5%

• head = 4.5% — 8.5%

• genitalia = 1%

Describe herpes zoster (shingles)

• initial Sx’s of pain & paresthesia localized to the affected dermatome

• painful rash w/ clusters of fluid-filled vesicles

• mostly unilateral

• raised to palpation

• pink w/ silvery white appearance

• CN 5 & 7 most commonly affected

What are some interventions for herpes zoster?

• refer

• TENS around affected area

• contact + airborne precautions

• antiviral meds

Describe the differences between herpes simplex HSV-1 & HSV-2

HSV-1

• oral lesions (cold sores, fever blisters)

• spread through saliva; dominant in trigeminal ganglion

• recurs w/ stress, sunlight, illness

HSV-2

• genital herpes w/ more frequent recurrences

• spread through sexual contact; dominant in sacral ganglia

• higher risk for neonatal transmission during childbirth

Describe Kaposi’s sarcoma

• viral infection caused by human herpes virus-8 (HHV-8)

• common in immunocompromised pts, esp. those w/ HIV/AIDS

• multiple red/purple/brown macules, plaques, or nodules often on skin, mucous membranes, or internal organs

• does not spread through contact

Describe cellulitis

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

• redness, warmth, swelling, tenderness

• often unilateral, associated w/ breaks in skin, edema, diabetes

• red flags: rapidly spreading redness, fever, systemic Sx’s

What are some interventions for cellulitis?

• systemic antibiotics

• elevate

• no massage or compression during acute stage

What do you look for when performing a wound exam?

• location & size: length x width x depth

• characteristics: granulation vs. nonviable tissue

• drainage & color

• edges: thin or thick (indurated), rolled (epibole)

• periwound

What are the phases of wound healing?

• inflammatory: immune response, clean wound base, increased O2 delivery

• proliferative: fibroblasts creates new weak collagen, angiogenesis (blood vessel production)

• maturation: strong type 1 collagen, increased tensile strength

What can cause delayed wound healing?

maceration & desiccation

What is maceration?

What causes this?

what happens to the wound edges & periwound if the wound is too moist

• white, friable, overhydrated, wrinkled skin

• d/t inappropriate wound care, uncontrolled wound drainage, perspiration, or incontinence

What is desiccation?

What causes this?

what happens to the wound & periwound if the wound is too dry

• d/t inappropriate wound care, inadequate moisture, infection, dehydration

What is selective debridement?

When should you choose this option?

removal of only nonviable tissues from a wound

• granulation tissue > dead tissue

What is non-selective debridement?

When should you choose this option?

removal of both nonviable & viable tissues from a wound

• dead tissue > granulation tissue

What are the options for selective debridement?

• sharp: use of scalpel, scissors, forceps (precise removal)

• enzymatic: use of topical enzymes (collagenase)

• autolytic: use of body’s own mechanism to remove nonviable tissue

• biologic (maggot therapy): sterile larvae digest necrotic tissue

What topical enzyme is used for enzymatic debridement?

collagenase

What are the options for non-selective debridement?

• wet-to-dry dressings: application of moistened gauze over area of necrotic tissue to be completely dried & removed

• wound irrigation: moves necrotic tissue from wound bed using pressurized fluid

• hydrotherapy: using a whirlpool w/ agitation directed toward the wound

What is the optimal wound irrigation pressure range?

When would you want it on the lower end?

When would you want it on the higher end?

4-15 psi

• lower end: for granulating wounds

• higher end: for heavily contaminated wounds or infected wounds

What are the dressing options based on very mild, minimal, moderate, heavy exudate, & infected wounds?

• very mild: transparent films

• minimal: hydrogels, hydrocolloid

• moderate: foams

• heavy: Ca2+ alginates, hydrofiber (max capacity)

• infected wounds: hydrofiber, Ca2+ alginates, hydrogels, gauze

What is the difference between stable eschar and unstable eschar?

How would you treat each of them?

• stable eschar: dry, leathery, & firmly adherent necrotic tissue acting as a protective barrier

  • left intact

• unstable eschar: soft, moist, draining, indicating infection/inflammation

  • requires debridement d/t infection risks