NPTE Integumentary

Layers of the skin

epidermis, dermis, subcutaneous/hypodermis

How to measure burns

Rule of 9's/Lund-Browder Chart

Hand Method

What is the Rule of 9's

For Adults:

Head and Neck - 9%

Anterior Trunk - 18%

Posterior Trunk - 18%

Each Arm - 9 %

Each Leg - 18%

Genitals - 1%

For Children

Head and Neck - 18%

Anterior Trunk - 18%

Posterior Trunk - 18%

Each Arm - 9%

Each Leg - 14%

Genitals - 1%

Wagner Ulcer Classification Scale

0 - no open lesion, healed ulcer, presence of bony deformity

1 - superficial ulcer

2 - deep ulcer including subcutaneous tissue; may expose bone, tendon, muscle

3 - deep ulcer with osteomyelitis

4 - gangrene of digit

5 - gangrene of foot requiring disarticulation

Pressure Ulcer Staging

Stage 1: intact skin, non-blanchable, pain, itching, firm or boggy

Stage 2: Partial thickness tissue loss, shallow open ulcer with red/pink wound bed, blisters

Stage 3: full thickness tissue loss into subcutaneous layer, slough, undermining, or tunneling

Stage 4: full thickness with exposed tendon, muscle, bone, slough, eschar, undermining/tunneling

Unstageable: full thickness covered by eschar/slough

Serous

clear, light color, thin, watery exudate

considered normal and seen during the inflammation stage of healing

Sanguineous Exudate

Red, bloody and thin water consistency. May be brown if dried

Serosanguineous exudate

thin, watery, and pale red to pink in color

Normal in healthy healing tissue seen in the inflammation and proliferation phases of healing

Seropurulent exudate

cloudy or opaque, with a yellow or tan color and a thin, watery consistency.

Early warning of infection

Abnormal

purulent exudate

Yellow or green color, thick, viscous consistency

Indicates infection

Abnormal

Wound Objective Measures

Examine for tunneling

Color

Temperature

Girth

Viability of peri wound tissue

Sensory integrity

Signs of infection

Wound scar tissue

Photographic records

Types of Burns

Thermal

Chemical

Electrical

Radiation

Thermal Burns

caused by heat

Electrical burns

Caused by passage of an electrical current through the body

Entrance and Exit wound

Complications of electrical burns

cardiac arrhythmias, respiratory arrest, renal failure, neurological damage, fractures

chemical burns

caused by contact with chemicals that can burn the skin

Reaction continues until the chemical is diluted at site of contact

Radiation burns

Occur from the absorption of radiation into the body

Complications of radiation burns

severe blistering and desquamation

non-healing wounds

tissue fibrosis

permanent discoloration

new malignancies

Zone of coagulation

cells are irreversibly injured, cell death occurs

zone of stasis

cells are injured; may die without specialized treatment, usually within 24-48 hours

zone of hyperemia

minimal cell injury; cells should recover

Classification of Burns

1st Degree

2nd Degree - superficial partial thickness

2nd Degree - deep partial thickness

3rd degree

4th degree

1st degree burn

Only the epidermis (red, painful, and edema)

2nd degree burn - superficial partial thickness

epidermis and superficial dermis

skin is pink, moist, and soft, thin walled blisters

local circulation disrupted

2nd degree burn - deep partial thickness

severe damage to epidermis and dermis

red or white, edema, blistering, severe pain

3rd degree burn

full thickness; all 3 layers damaged

not painful

Risk of contracture d/t damage to muscle/tendons

4th degree burn

full-thickness burn extending to muscle or bone

4 types of ulcers

arterial

venous

neuropathic

pressure/decubitus

Arterial insufficiency ulcers

Secondary to ischemia of the lower legs

smooth well-defined edges "Punched out" deep, dry, cool to the touch

Diminished or absent pedal pulse

Thin and shiny skin

hair loss

yellow nails

leg elevation increases pain

venous insufficiency ulcers

Secondary to insufficient venous return

Location: Proximal to medial malleolus

irregular and shallow

large amounts of pus

moderate amount of pain

normal pedal pulse

brown discoloration of the skin

leg elevation decreases pain

Neuropathic Ulcers

Secondary to diabetic neuropathy, peripheral vascular disease, and absence of protective sensation

Typically occur on areas of the feet susceptible to pressure and shear forces during WBing

Wound is typically well defined with callused wound edge

Pedal pulses are diminished or absent

Decubitus ulcers

Pressure sores from prolonged immobility

Abrasion

wound caused by a combination of friction and shear forces, typically over a rough surface. scraping away of the skin's superficial layers

Avulsion

An injury in which soft tissue is torn completely loose or is hanging as a flap.

Laceration

A wound or irregular tear of the flesh often associated with trauma

penetrating wound

an open wound that breaks the skin and enters a body area, organ, or cavity

puncture wound

a deep hole made by a sharp object

relatively little tissue damage beyond the wound tract

Skin tear

a traumatic wound resulting from separation of the epidermis from the dermis

Dermatitis

inflammation of the skin that includes crusty, dry patches, itching, oozing, dryness, and rashes d/t to an irritating agent

impetigo

bacterial skin infection characterized by isolated pustules that become crusted and rupture. contagious

cellulitis

Inflammation of cellular or connective tissue

Poorly defined and widespread Skin is hot, red and edematous

Can be contagious

Abscess

Cavity containing pus and surrounded by inflamed tissue

Result of localized infection

Ringworm

a fungal infection of the skin, hair nails that appears in circular lesions and is itchy

Athletes foot

Fungus infection usually in the skin of the toes and soles. Can progress to cellulitis if untreated

Erythema, itching, pain

Scabies

contagious skin disease transmitted by the itch mite that burrows into the skin

inflammation, itching

Lice

small insects that attach to hair and feed on human blood

Psoriasis

chronic skin condition producing red lesions covered with silvery scales

Lupus Erythematosus

Chronic progressive autoimmune disorder causing fibrosis of the skin, joints, BVs, and internal organs

red scaly rash of the trunk and face (butterfly distribution)

polymyositis

a muscle disease characterized by the simultaneous inflammation and weakening of voluntary proximal muscles

herpes simplex

Recurring viral infection that often presents as a fever blister or cold sore.

herpes 2

genital herpes

herpes zoster

shingles; reemergence of the chicken pox virus primarily in adults

pain, tingling, red papules in dermatome pattern

Warts

Benign infection by HPV contagious through touch

Benign Skin Cancer

Seborrheic keratosis

Actinic keratosis

Benign nevus

Malignant Skin Cancers

Basal cell carcinoma

squamous cell carcinoma

malignant melanoma

Allow Graft

Use of other human skin for a temporary graft for large burns; used until autograft is available

Xenograft

use of skin from another species; temporary

biosynthetic graft

combination of collagen and synthetics

Cultured Skin graft

Lab grown from patient's own skin

autograft

skin graft from a person's own body

split thickness graft

contains epidermis and upper layers of dermis from donor site

full thickness graft

epidermis and dermis from donor graft

z-plasty graft

surgical resection of scar contracture; used to lengthen a burn scar

Dressings for dry wounds

hydrocolloid

semi-permeable films

non-adherent island dressing

hydroid

Dressings for wounds with minimal exudate

hydrocolloid

hydrogel

silicone

transparent film

Dressings for moist wounds

foams

calcium alginate

negative pressure

hydrocolloid paste/power

types of selective debridement

sharp, enzymatic, autolytic

types of non-selective debridement

wet-to-dry

hydrotherapy

irrigation

Wound Pressure Therapy (wound vac)

Non-invasive; facilitates healing and manages wound drainage

used for chronic or acute wounds that cannot be closed by primary intention

Hyperbaric Chamber

Inhalation of 100% oxygen at 2 3x the pressure of the atmosphere. Reduces edema, hyperoxygenates tissue

used for:

Thermal burns

Compromised flaps/grafts

Diabetic wounds

Osteomyelitis

Necrosis

Growth Factors

Facilitate healing by stimulating the activity of specific cell types; typically, a topical application

used for neuropathic ulcers with adequate circulation

Compression Garments

sustained compression from 15-35 mmHg to improve hypertrophic scarring

Scar Massage

Technique to improve scar tissue flexibility.