Other Systems- Integumentary

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  1. Name the different layers of the skin
    • epidermis
    • dermis
    • subcutaneous layer
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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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Other Systems- Integumentary
2012-12-18 03:15:53
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Other Systems- Integumentary
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