Wound Care and Skin Integrity Part 2
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| Serosanguinous or Sanguinous | looks like watery blood - Hemorrhagic - due to capillary damage - Occurs w/severe inflammation/ injury
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| Purulent | Pus Occurs with infection - Thicker, WBCs, dead tissue, & bacteria, Pyogenic – bacteria produced - may be yellow, tan, green,
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| Mucus (mucous) | thick fluid secreted by mucous membranes and glands
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| Phase 4 – Healing | Regeneration and repair - Replacement of lost cells & tissue w/cells of same type
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| What factors may prolong inflammatory phase? | age, autoimmune disease, chronic infections, nutrition deficiencies, immunosuppressants, steroids
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| What might impair granulation or proliferation phase? | dry wound, infection, nutrition (not enough protein or zinc), collagen, anemic (not enough RBCs to get there and heal)
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| Hyperemia | redness due to vasodilation – blanch to see if transient
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| Blanching hyperemia | area blanches and then erythema returns – transient
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| Nonblanching erythema | area does not blanch – deep tissue damage probable
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| In shear, what damage occurs? | deep tissue damage – undermining of dermis
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| In friction, what damage occurs? | epidermis or top layer of skin – sheet burn
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| Skin changes due to age | reduc skin elasticity, decr collagen, slower epithelialization & wound healing, dypodermis decreases in size, less sub Q
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| Primary Intention | Wound closed with sutures, staples, dermabond, Least scarring
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| Secondary Intention | Left open to fill in w/granulation tissue – healing from inside out
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| Why use secondary intention? | To monitor granulation tissue or remove necrotic tissue –adipose tissue takes longer to heal
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| Tertiary Intention or delayed primary closure | wound left open for a period of time & then closed – used w/compartmental syndrome, make sure infection gone before closing
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| Examples of primary intention | surgical incision closed w/suture or staples
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| How does primary intention heal? | by epithelialization – minimal scar formation – by connective tissue deposition
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| How does secondary intention heal? | By granulation tissue formation, wound contraction, and epithelialization
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| Examples of secondary intention | pressure ulcers, burn, severe laceration, surgical wounds w/tissue loss – wound edges not approximated
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| Examples of tertiary intention | contaminated wounds – examining them for inflammation
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| How does tertiary intention heal? | closure of wound delayed until risk of infection, then closed
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| Full thickness wounds heal by | skar formation because deeper structures do not regenerate
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| 3 healing stages of partial-thickness wounds | inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of epidermis
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| 3 healing phases of full-thickness wound repair | inflammatory, proliferative, and remodeling
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| How do steroids affect healing? | suppresses the immune system, masks effects of infection
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| How does infection delay healing? | Uses up available resources, damages tissues
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| Inflammatory Phase | hemostasis, fibrin matrix, neutrophils, then monocytes that transform into macrophages – goal is to stop bleeding and remove debris
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| Proliferative Phase | appearance of new blood vessels, granulation tissue, contraction of wound, epithelialization, collagen
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| What can impair healing during proliferation phase? | age, anemia, hypoproteinemia, and zinc deficiency
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| Remodeling phase | collagen scar formation – takes more than year – scar is remodeled and reorganized into original appearance
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| Hemorrhage occurring after hemostasis indicates? | slipped surgical suture, dislodged clot, erosion of blood vessel by drain, etc.
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| Surgical wound doesn’t show infection till when? | 4th or 5th postoperative day
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| Dehiscence | surgical incision has opened - pack w/moist gauze, etc; monitor for signs of infection
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| Increase in serosanguineous drainage from wound could indicate | dehiscence
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| Evisceration | medical emergency – when organ protrudes outside body - dehiscence - cover w/sterile moist gauze over protruding organ & surgery – NPO
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| What can increase incidence of dehiscence and evisceration?Obesity, poor suturing, poor nutrition |
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| Fistula | poor wound healing – abnormal passage between 2 organs or between organ and outside of body
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| How do fistulas occur | poor wound healing or complication of disease, trauma, infection, radiation, cancer – tissue layers don’t’ close properly
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| s/sx of internal bleeding? | hematoma, bruising, distention, BP drop, HR incr due to loss of volume, hypotension, tachycardia
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| Contracture | excessive shortening of muscle or scar tissue leads to deformity – when arm or affected parts are immobilized
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| PRESSURE – 3 factors for pressure wounds | Pressure Intensity, Pressure Duration, Tissue Tolerance
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| Impaired Nutrition that affects wounds | not enough protein, zinc, vitamin C
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| Stage I | Superficial, Intact skin, Non-blanchable erythema, Discoloration of darker skin, Warmth, edema (boggy feeling), induration, hardness
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| Stage II or partial thickness | Partial loss of epidermis & dermis, abrasion, blister, Considered infected even if no sx – heals by regeneration
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| Stage III or full thickness | deep crater, Extends into SQ tissue, but not into muscle, necrosis present - slough or eschar – heals by scar formation
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| Stage IV – Full thickness | through SQ into muscle w/extensive destruction, necrosis – may go down to the bone, possible damage to muscle, bone, supporting structures – scar formation
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| How do stage 3 and 4 wounds heal? | through scar formation
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| How does a stage 2 wound heal? | by regeneration
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| Venous stasis ulcers | necrotic crater-like lesion usually found on lower leg at medial malleoli - slow to heal, poor venous return, varicose veins, incompetent valves, DM, arterioscleosis
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| Arterial ulcers | pale, ischemic base, well defined edges found on toes, heels, lateral malleoli
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| Cap refill in arterial ulcer | Greater than 3sec
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| Cap refill in venous ulcer | Less than 3sec
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| Which type of ulcer condition has no edema in the legs, yet has little or no hair there? | arterial
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| Cool skin temperature occurs in which type ulcer? | arterial – venous is warm
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| Contact Dermatitis | caused by exposure to irritant chemical or allergen - poison ivy, metals – nickel
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| Atopic Dermatitis (Eczema) | tendency is inherited causing chronic inflammation from exposure to allergens
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| Urticaria (hives) | type I hypersensitivity reaction (usually caused by something ingested) causing release of histamines – wheals
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| Psoriasis | Unknown origin - Chronic rapid turnover of epidermal cells resulting in thickening and scaling, silvery plaques
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| Cellulitis | infection of dermis & subcutaneous tissue; may be caused by Staph or Strep, insect bite - MRSA, Red, warm, swollen, painful
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| Furuncles | usually cause by Staph which begins in a hair follicle & spreads into surrounding dermis – boil
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| Carbuncle | collection of furuncles that form a large infected mass – if many furuncles together, they are a carbuncle.
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| Acute Necrotizing Fascitis | highly virulent strain of gram positive, group A, beta-hemolytic Strep, history of minor trauma or infection in skin and subQ - Mortality is 30-60%
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| Herpes Zoster (Shingles) | Caused by activation of varicella-zoster virus - affects one cranial nerve or one dermatome innervated by a spinal nerve
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| Cutoff score for onset of pressure ulcer risk with Braden Scale is | 18
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| Tinea infections | fungal infection or mycoses
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| Pedis | athlete’s foot
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| Corporis | ringworm of body
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| Capitus | ringworm of head
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| Pediculosis (lice) | contagious parasites that suck blood - head, body, pubic
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| Scabies | contagious, caused by itch mite - Causes burrows, papules, vesicles; very itchy
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| Vitamin A reduces neg effects of | steroids on wound healing
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| Copper is necessary for | collagen fiber linking
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| Best measure of nutritional status is | prealbumin – reflects not only what pt eats but what body has absorbed
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| Basal cell | can be removed. Most common, least likely to metastasize
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| Squamous cell | removal, may require radiation. May metastasize if untreated
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| Malignant Melanoma | Excision & removal of surrounding tissue, Lymph node biopsy, radiation, chemo, immune therapy, A symmetry, B orders irregular, C olor-varied pigmentation brown, black, tan, D iameter > 6mm - pencil eraser
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| Wrinkles – Why? | loss of elasticity
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| Skin tears | lose collagen
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| Senile lentigo or liver spots | areas of discoloration on the skin – tannish - harmless
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| Pruritis | itching due to dry skin
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| Keratosis | overgrowth of horny layer
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| Seborrheic | yellow-brown scales on trunk, face, scalp
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| Macule | frecke, petechia, flat nonpalpable change in skin color – smaller than 1cm
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| Papule | Nevus – palpable, circumscribed, solid elevation in skin – smaller than 1cm
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| Nodule | Wart – elevated solid mass deeper and firmer than papule 1-2 cm
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| Wheal | Hive, mosquito bite – irregularly shaped, elevated areas of superficial localized edema – varies in size
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| Vesicle | Chickenpox, herpes – circumscribed elevation of skin filled w/serous fluid, less than 1cm
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| Pustule | Acne, staphylococcal infection – like a vesicle but filled with pus
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| Ulcer | Venous stasis ulcer – deep loss of skin – extends to dermis – bleeds and scars
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| Atrophy | Arterial insufficiency – thinning of skin w/furrow – skin shiny and translucent
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| Plaque | a patch on the skin or on a mucous surface
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| Fissure | an ulcer or cracklike sore
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| Comedone/comedo | The typically small skin lesion of acne – closed form is a whitehead – papule – open form is a blackhead- rearely inflamed
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| Petichiae | pinpoint purpuric lesions – tiny bruises
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| Purpura | any rash in which blood leaks into skin at multiple sites – associated mostly with coagulation or thrombosis disorders
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| Ischemia (decreased circulation) - disorders causing | PVD, MI, DVT, CVA
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| Causes inflammation without infection | Foreign body, Ischemia, Skin, tissue trauma, Temp extremes (Burns, frostbite), Chemicals, radiation, electricity, Allergies, Neoplasms
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| Differentials measure | WBC count incl. neutrophils, lymphs, monos, eosinophils/basophils
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| Neutrophils increase with | bacterial infections or acute trauma – major inflammatory response
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| Which WBCs are the first to respond? | neutrophils – perform phagocytosis
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| Lymps increase with | viral & chronic bacterial infections
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| Monos change into | macrophages in tissues – phagocytosis
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| Monos increase with | protozoan, rickettsial, & TB infections, fungal
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| Eosinphils/Basophils increase with | allergic rxns, not elevated with infections, release chemical that control histamine & serotonin
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| Which WBCs release chemicals that control histamine & serotonin? | Eosinophils/basophils – due to allergic rxn, not infections
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| Total WBCs | 4000-10000/mm3
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| Possible critical levels are WBCs | less than 2500 or greater than 30,000 or Absolute neutrophils less than 1000
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| Elevated sedimentation rate Increase w/ | generalized inflammatory response
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| C-reactive protein increase w/ | inflammation, infection, malignancy
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