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Name the different layers of the skin
- epidermis
- dermis
- subcutaneous layer
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Name and describe the different phases of wound healing
- inflammatory phase: 1-10 days, initial response to a wound, platelet activation and clotting cascade occurs, begin tissue restoration and permanent repair process (epithelialization usually starts within 24 hours)
- proliferative phase: 3-21 days, formation of new tissue, capillary buds and granulation tissue fill the wound bed, skin integrity is restored
- maturation phase: 7 days- 2 years, remodeling phase, granulation tissue and epithelial differentiation begin to appear in wound bed, scar begins to shrink and thin
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Describe the 3 different methods of healing by intention
- primary intention: acute wounds with minimal tissue loss, smooth clean edges are reapproximated and closed, may need sutures or staples
- secondary intention: significant tissue loss or necrosis, irregular or nonviable wound margins that can't be reapproximated... ongoing wound care
- tertiary intention: wounds at risk for developing complications, such as sepsis or dehiscence so may be left open
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Arterial ulcer characteristics and recommendations
- Recommendations: avoid leg elevation, avoid heating pads or soaking feet, limb protection
- location: lower 1/3 of leg, web spaces, dorsal foot, lateral malleolus
- appearance: smooth edges, tend to be deep
- sever pain and minimal exudate
- pulses: diminished or absent
- skin temp: decreased
- tissue change: thin and shiny
- leg elevation INCREASES pain
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Venous ulcer characteristcs and recommendations
- Recommendations: compression to control edema, elevate legs above heart
- location: proximal to medial malleolus
- appearance: irregular
- exudate: moderate/heavy
- edema: increased
- tissue changes: flaky/dry skin, brownish in color
- leg elevation DECREASES pain
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Neuropathis ulcer characteristics and recommendations
- Recommendations: inspect footwear for debris
- Location: areas of foot susceptible to pressure
- appearance: well defined circle, callused rim
- exudate: low to moderate
- pulse: diminished or absent, unreliable ABI if have DM
- skin temp: decreased
- tissue changes: dry, inelastic, shiny skin
- LOSS OF PROTECTIVE SENSATION
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Wagner Ulcer Grade Classification Scale
- 0: no open lesion
- 1: superficial ulcer not involving subcutaneous
- 2: deep ulcer w/ penetration through the subcutaneous tissue- potentially exposing bone, tendon, ligament, or joint
- 3: deep ulcer with osteitis, abscess or osteomyelitis
- 4: gangrene of digit
- 5: gangrene of foot
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Pressure Ulcer Staging
- I: intact skin with non-blanchable redness
- II: partial thickness loss of dermis, shallow ulcer w/ red/pink wound bed, serum filled blisters, no slough
- III: full thickness loss, subcutaneous may be visible but NO muscle tendon or bone, may have undermining or tunneling
- IV: full thickness tissue loss with exposed bone, tendon or muscle
- suspected deep tissue: puple or maroon localized areas of intact skin or blood filled blister due to damage of underlying soft tissue
- unstageable: full thickness tissue loss in which the base is covered in slough
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Exudate types
- serous: clear, light color, thin, NORMAL in inflammatory & proliferative phases
- sanguineous: red, thin, watery, indicative of new blood vessel growth
- serosanguineous: light red or pink, thin, watery, NORMAL in inflammatory & proliferative phases
- seropurulent: cloudy or opaque, yellow or tan, EARLY WARNING SIGN OF INFECTION
- purulent: yellow or green, INDICATES WOUND INFECTION
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Selective debridement characteristics
- Sharp: can be used with sepsis or cellulitis, quickest way to remove necrotic tissue
- Enzymatic: topical aplication, infected or non-infected wounds, usually use autolytic first, slow process
- Autolytic: uses body's own enzymes, longer healing period, can't use on infected wounds
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Non-selective debridement characteristics
- wet to dry dressings: bad part is will pull up granulation tissue with exudate and necrotic tissue
- wound irrigation: uses pressurized fluid to remove necrotic tissue
- hydrotherapy: some side effects are maceration of viable tissue, edema from dependent position, hypotension
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4 types of burns
- thermal: caused by conduction or convection
- electrical burn: electrical current through body, usually an entrance and exit wound, can cause cardiac arrythmias, respiratory arrect, renal failure
- chemical burn: chemical compounds come in contact w/ body- sulfuric acid, hydrochloric acid
- radiation bun: exposure to external beam radiation therapy and DNA is altered
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Different Zones of burns
- Zone of coagulation: area of burn w/ most serious injury
- Zone of stasis: area of less severe injury, reversible damage
- Zone of hyperemia: surrounds zone of stasis but presents with inflammation
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Burn Classification
- superficial burn: outer epidermis, 2-5 days healing
- superficial partial-thickness burn: epidermis & upper portion of the dermis, extremely painful, blisters, 5-21 days healing
- deep partial thickness burn: epidermis and majority of dermis, damage to nerve endings, keloid scarring may occur, 21-35 days
- full thickness burn: epidermis, dermis, subcutaneous fat layer, eschar formation & minimal pain, often require grafts, healing time varies with size
- subdermal burn: epidermis, dermis, subcutaneous tissue, & may have muscle and bone
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Rule of Nines
- head and neck: 9%
- anterior trunk: 18%
- posterior trunk: 18%
- bilateral anterior arm, forearm, hand: 9%
- bilateral posterior arm, forearm, hand: 9%
- genital region: 1%
- bilateral anterior leg and foot: 18%
- bilateral posterior leg and foot: 18%
- kids have 9% taken from LEs and added to head/neck
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Skin graft terminology
- allograft: temporary skin graft
- autograft: permanent skin graft taken from own donor site
- escharotomy: open or remove eschar from burn site to reduce tension and pressure to help w/ circulation
- full thickness graft: graft contains dermis and epidermis
- mesh graft: mesh like pattern to cover larger surface area
- split thickness graft: contains only superficial layer of dermis with epidermis
- heterograft (xenograft): temporary graft taken from another species
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Cellulitis
- fast spreading inflammation from bacterial infection of skin & connective tissues
- S/S: localized redness, warm to touch, tenderness
- RULE OUT DVT and contact dermatitis
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Wound Classification by depth of injury (not pressure or neuropathic ulcers)
- superficial wound: epidermis intact, non-blistering sunburn
- partial thickness wound: epidermis and partially into dermis- abrasions, blisters, skin tears
- full thickness wound: epidermis, dermis, subcutaneous fat, usually heal by secondary intention, 4 mm deep
- subcutaneous wound: involve deeper structures- fat, muscles, tendon, bone, usually heal by secondary intention
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