Term
| total skin thickness range |
|
Definition
|
|
Term
| skin thickness differs mostly in which layer of the skin |
|
Definition
|
|
Term
|
Definition
| protection, thermal regulation, sensation |
|
|
Term
| integumentary system also contains these (4) |
|
Definition
| follicles, nails, sweat galnds, sebacous glands |
|
|
Term
| what are the 2 primary components of the skin |
|
Definition
|
|
Term
| epidermis thickness range |
|
Definition
|
|
Term
| thickest portions of the epidermis |
|
Definition
|
|
Term
| 2 other characteristcs of the epidermis |
|
Definition
| avascular, comprised of five layers or "strata" |
|
|
Term
|
Definition
| protection against injury, barrier to water loss, provides light touch sensation, protection from uv radiation, assists with excretion of waste (sweat) vitamin d production, defense against microorganisms, harmful chemicals |
|
|
Term
| 4 types of epidermal cells |
|
Definition
| keratinocytes, melanocytes, langerhans cells, markel cells |
|
|
Term
| epidermal cells: 90%, most important cell, main structural element, tough insoluble protein |
|
Definition
|
|
Term
| epidermal cells: 5%, provide color of skin and UV protection |
|
Definition
|
|
Term
| epidermal cells: fight infection |
|
Definition
|
|
Term
| epidermal cells: mechanoreceptors for light touch info and involved with nerve growth factor |
|
Definition
|
|
Term
| thickness range of the dermis |
|
Definition
|
|
Term
| two main layers of dermis |
|
Definition
|
|
Term
| dermis: thin layer helps adhere to epidermis |
|
Definition
|
|
Term
| dermis: thicker layer at base of dermis. Gives toughness to skin. Contains cutaneous blood vessels |
|
Definition
|
|
Term
|
Definition
| protection against mechanical injury, supports and nourishes epidermis |
|
|
Term
|
Definition
| muscle fibers, hair follicles, sweat and sebaeous glands |
|
|
Term
|
Definition
| infection control and thermoregulation |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| what does subcutaneous tissue consist of |
|
Definition
|
|
Term
| purpose of adipose tissue (3) |
|
Definition
| energy, cushioning, insulation |
|
|
Term
| highly fibrous tissue located in hypodermis/subcutaneous tissue |
|
Definition
|
|
Term
| purpose of subcutaneous tissue |
|
Definition
| separate and surround structures to facilitate movement between adjacent structures |
|
|
Term
| 3 phases of wound healing |
|
Definition
| inflammatory, proliferation, maturation (remodeling) |
|
|
Term
| Inflammatory Phase: involves what tissues |
|
Definition
| vascular and cellular tissue |
|
|
Term
| Inflammatory Phase: does not occur in what? |
|
Definition
| dead tissue or tissue without blood supply |
|
|
Term
| Inflammatory Phase: is the body's ______ system response |
|
Definition
|
|
Term
| Inflammatory Phase: lasts how many days normally |
|
Definition
|
|
Term
| Inflammatory Phase: is a result of what |
|
Definition
| exudate in interstitial tissue due to vasodilation and increased membrane permeability |
|
|
Term
| Inflammatory Phase: cardinal signs (5) |
|
Definition
| swelling, pain, redness, warmth, decreased function |
|
|
Term
| Inflammatory Phase: cells involved in this phase (4) |
|
Definition
| platelets, neutrophils, macrophages, mast cells |
|
|
Term
| Inflammatory Phase: goal of these cells |
|
Definition
| control bleeding, kill bacteria/clean wound, begin repair process |
|
|
Term
| Proliferation Phase: basic goals |
|
Definition
| remodeling and rebuilding phase |
|
|
Term
| Proliferation Phase: overlaps with which phase |
|
Definition
|
|
Term
| Proliferation Phase: begins up to how many days post injury |
|
Definition
|
|
Term
| Proliferation Phase: lasts up to how long |
|
Definition
|
|
Term
| Proliferation Phase: purpose of this phase |
|
Definition
| fill and resurface wound bed, restore skin integrity |
|
|
Term
| Proliferation Phase: 4 evenets |
|
Definition
| angiogenesis, granulation tissue formation, wound contraction, epithelialization |
|
|
Term
| formation of new blood vessels |
|
Definition
|
|
Term
| Proliferation Phase: what does angiogenesis help with |
|
Definition
| improved nutrition and removal of waste from teh wound bed |
|
|
Term
| Proliferation Phase: granulation tissue formation aka |
|
Definition
|
|
Term
| Proliferation Phase: temporary vascularized connective tissue that fills teh wound bed |
|
Definition
|
|
Term
| Proliferation Phase: cells that fill space between collagen and elastic fibers |
|
Definition
|
|
Term
| Proliferation Phase: granulation tissue is eventually replaced by what |
|
Definition
|
|
Term
| Proliferation Phase: wound contraction: fibroblasts transform to what |
|
Definition
|
|
Term
| Proliferation Phase: wound contraction: role of the myofibroblasts |
|
Definition
| pull wound margins together |
|
|
Term
| Proliferation Phase: event which accounts for up to 40% decrease in size of wound |
|
Definition
|
|
Term
| Proliferation Phase: wound contraction: which wound shape contracts the quickest |
|
Definition
|
|
Term
| Proliferation Phase: wound contraction: which wound shape contracts 2nd fastes |
|
Definition
|
|
Term
| Proliferation Phase: wound contraction: which wound shape contracts the 3rd fastest |
|
Definition
|
|
Term
| Proliferation Phase: wound contraction: which wound shape contracts the slowest |
|
Definition
|
|
Term
| Epithlialization: occurs how? |
|
Definition
| simultaneously with over events |
|
|
Term
| Epithlialization: how does this event occur simultaneously? |
|
Definition
| granulation tissue fills wound bed, epithelial cells at wound edge multiply and migrate across wound bed, granulation tissue grows due to vascular need |
|
|
Term
| Maturation and Remodeling Phase: wound healing is not finished until what? |
|
Definition
|
|
Term
| Maturation and Remodeling Phase: how long can this process take? |
|
Definition
|
|
Term
| Maturation and Remodeling Phase: reorganization of what? |
|
Definition
| collagen fibers, scar formation |
|
|
Term
| Maturation and Remodeling Phase: a pink scar says what? |
|
Definition
| remodeling still taking place |
|
|
Term
| Maturation and Remodeling Phase: a white scar says what? |
|
Definition
|
|
Term
| Maturation and Remodeling Phase: strength of remodeled skin/scar |
|
Definition
| 70% to 80% of original skin strength |
|
|
Term
|
Definition
| primary, secondary, teritiary |
|
|
Term
| Primary intention wound closure types |
|
Definition
| surgical sutures, flaps, grafts |
|
|
Term
| healing of primary intention wound closures |
|
Definition
| heals well d/t low tension across wound bed with good vasculature |
|
|
Term
| type wound closure with secondary intention |
|
Definition
| closure via epithelialization and contraction |
|
|
Term
| healing of secondary intention wound closure |
|
Definition
| requires more time and energy and will result in a larger scar |
|
|
Term
| tertiary intention wound closure types |
|
Definition
| combo of primary and secondary |
|
|
Term
| How are tertiary intention wounds healed? |
|
Definition
| start to heal with secondary the primary intention is done |
|
|
Term
| why does tertiary intention wound closure start with the secondary intention |
|
Definition
| allow debris to continue to clear, monitor wound for infection |
|
|
Term
| when does primary intention wound closure begin during teritary intention wound closure |
|
Definition
| after the wound is clear of debris |
|
|
Term
| signs of abnormal wound healing (7) |
|
Definition
| lack of inflammation, chronic inflammation, hypogranulation, hypergranulation, hypertrophic scarring, contractures, dehiscence |
|
|
Term
| Abnormal Wound Healing: lack of inflammation, what should you do? |
|
Definition
| need to clean wound and call in healing cells |
|
|
Term
| Abnormal Wound Healing: why is chronic inflammation bad? |
|
Definition
| doesn't allow new tissue to be built |
|
|
Term
| Abnormal Wound Healing: why is hypogranulation bad? |
|
Definition
| wound doesn't build enough granulation tissue to fill the wound bed, so its like a pot hole |
|
|
Term
| Abnormal Wound Healing: why is hypergranulation bad |
|
Definition
| granulation tissue continues to form even after wound bed is filled. Epithelial cells continue to grow over the wound |
|
|
Term
| Abnormal Wound Healing: why is hypertrophic scarring bad |
|
Definition
| overproduction of immature collagen during proliferative and maturation phases results in raised, red, and fibrous scar, especially in darker skinned individuals |
|
|
Term
| Abnormal Wound Healing: shortening of scar tissue |
|
Definition
|
|
Term
| Abnormal Wound Healing: insufficient scar formation |
|
Definition
|
|
Term
| Abnormal Wound Healing: what happens as a result of dehiscence |
|
Definition
| wound edges split open or separate |
|
|
Term
| 7 classifications of wound |
|
Definition
| traumatic, pressure ulcers, ischemic, diabetic, venous insufficiency, burns, dehisence |
|
|
Term
| examples of traumatic wounds (3) |
|
Definition
| MVA, laceration, gun shot wound |
|
|
Term
| ischemic wounds are a ersult of what |
|
Definition
| lack of blood supply and of oxygen |
|
|
Term
|
Definition
| thermal, chemical, electrical |
|
|
Term
| if the wound depth is only superficial, what layer of the skin does it only effect? |
|
Definition
|
|
Term
| a partial thickness wound will affect which layers of the skin |
|
Definition
|
|
Term
| example of a partial thickness wound |
|
Definition
| second degree sun burn with blistering |
|
|
Term
| contraction of edges of partial thickness wounds |
|
Definition
|
|
Term
| full thickness wounds affect what (3) |
|
Definition
| epidermis, dermis, structures |
|
|
Term
| example of full thickness wound |
|
Definition
| stage IV pressure sore resulting in exposed bone |
|
|
Term
| where does epithelium migrate from for partial thickness wounds |
|
Definition
| edges and dermal appendages |
|
|
Term
| where does epithelum migrate from for full thickness wounds |
|
Definition
|
|
Term
| how do full thickness wounds heal |
|
Definition
| by contraction of wound edges |
|
|
Term
| why is it bad when full thickness wounds heal by contraction of wound edges? |
|
Definition
| there is a large open area under the wound increasing the chance for infection |
|
|
Term
| uncomplicated, orderly, rapid healing wound |
|
Definition
|
|
Term
| prolonged or lengthy healing process wound |
|
Definition
|
|
Term
| localized area of necrosis that develops when soft tissue is compressed between a firm surface and an underlying bony prominence |
|
Definition
|
|
Term
| 3 mechanicms for pressure ulcers |
|
Definition
| friction, moisture, shear |
|
|
Term
| patient populations most susceptible ot a pressure ulcer |
|
Definition
| SCI, DM< hospitalized patients, patient's in LTC settings |
|
|
Term
| most frequent sites for pressure ulcers |
|
Definition
|
|
Term
| pressure ulcers: nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. |
|
Definition
|
|
Term
| pressure ulcers: partial thickness skin loss involving epidermis and/or dermis. THe ulcer is superficial and apepar clinically as an abrasion, blister, or shallow crater |
|
Definition
|
|
Term
| pressure ulcers: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The ulcer appears clinically as a deep crater with or without undermining of adjacent tissue |
|
Definition
|
|
Term
| pressure ulcers: full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts may also be associated with stage IV pressure ulcers |
|
Definition
|
|
Term
| predisposing factors: arterial ulcers |
|
Definition
| PVD, diabetes, advanced age |
|
|
Term
| predisposing factors: venous ulcer |
|
Definition
| valve incompetence, hx of DVT, advanced age, obesity, CHF |
|
|
Term
| predisposing factors: diabetic ulcer (neuropathic) |
|
Definition
| diabetes with peripheral neuropathy, sensory, motor, autonomic |
|
|
Term
| assessment of: arterial ulcer |
|
Definition
| thin, shiny, dry skin. Loss of hair on ankle/foot. Thickened toe nails, cyanosis, cool to touch, absent pulses |
|
|
Term
| assessment of: venous ulcer |
|
Definition
| firm edema, lipdermatosclerosis (Scaling and crusting), may be increased temp, normal pulse |
|
|
Term
| assessment of: diabetic ulcer |
|
Definition
| less or absent sensation, foot deformities (charcot), increased temperature, palpable pulse |
|
|
Term
|
Definition
| between toes, tips of toes, distal lateral leg, lateral malleolus, at rubbing of footwear |
|
|
Term
|
Definition
| medial aspect of lower leg, may extend to malleolar area, anterior and lateral shin |
|
|
Term
| wound location: diabetic (neuropathic) |
|
Definition
| plantar aspect of foot, over metatarsal heads, under heel |
|
|
Term
| wound characteristics: arterial |
|
Definition
| irregular edge, punched out look, deep, possible tendons exposed, base if often pale, gangrene, necrosis, painful, increased pain with elevation, intermittent claudications may progress to resting pain |
|
|
Term
| wound characteristics: venous |
|
Definition
| irregular wound edges, shallow diffuse edges, superficial, ruddy granular tissue, fibrous debris, excessive exudate, may be painless, often a dull aching pain increasing throughout the day and decreases with elevation |
|
|
Term
| wound characteristics: diabetic (neuropathic) |
|
Definition
| even wound edges, deep, callous formation around plantar wounds, granular tissue present, painless |
|
|
Term
| periwound characteristics: arterial |
|
Definition
| black necrotic skin may surround, pale |
|
|
Term
| periwound characteristics: venous |
|
Definition
| hemosiderin-brown staning, woody, weeping with mutliple openings, edematous |
|
|
Term
| periwound characteristics: diabetic (neuropathic) |
|
Definition
|
|
Term
| Skin dryness in non injured skin can lead to |
|
Definition
| cracking of skin, loss of epithelial cells as they dry up and flake off |
|
|
Term
| Skin dryness in an existing wound leads to what |
|
Definition
| slowed epithelialization and usually painful |
|
|
Term
| excessive moisture on non injured skin will result in what |
|
Definition
| maceration (softening, whitening of skin) |
|
|
Term
| excessive moisture in an existing wound will lead to what |
|
Definition
| macerated edges of wound and can increase in size |
|
|
Term
| scale for predicting pressure sore risk |
|
Definition
|
|
Term
| braden's scale for predicting pressure sore risk includes what (5) things? |
|
Definition
| sensory perception, moisture, activity, mobility, nutrition, friction and shear |
|
|
Term
| Braden's Scale for Pressure Sore Risk: importance of sensory perception |
|
Definition
| ability to respond to pressure-related stimuli. completely limited to no impairment |
|
|
Term
| Braden's Scale for Pressure Sore Risk: importance of moisture |
|
Definition
| degree which skin is exposed to moisture. constantly to rarely moist |
|
|
Term
| Braden's Scale for Pressure Sore Risk: importance of activity |
|
Definition
| degree of physical activity. bedfast to walks frequently |
|
|
Term
| Braden's Scale for Pressure Sore Risk: importantance of mobility |
|
Definition
| ability to alter and control body position. completely immobile to no limitation |
|
|
Term
| Braden's Scale for Pressure Sore Risk: importance of nutrition |
|
Definition
| usual food intake. very poor to excellent |
|
|
Term
| Braden's Scale for Pressure Sore Risk: importance of friction and shear |
|
Definition
| problem to no apparent problem |
|
|
Term
| Braden's Scale for Pressure Sore Risk: score is less than 12 means what |
|
Definition
| high/risk for pressure sore |
|
|
Term
| Braden's Scale for Pressure Sore Risk: score is between 13-15 |
|
Definition
|
|
Term
| Braden's Scale for Pressure Sore Risk: 16-18 |
|
Definition
|
|
Term
| Braden's Scale for Pressure Sore Risk: 18 or higher |
|
Definition
| low risk of pressure sore |
|
|
Term
| removal of necrotic tissue, foreign material, and debris from the wound bed |
|
Definition
|
|
Term
| purpose of debridement: decrease..(3) |
|
Definition
| baceterial concentration in wound bed, thus decreasing risk of infection, decrease energy needed by the body for wound healing, decrease wound odor |
|
|
Term
| purpose of debridement: increase |
|
Definition
| effectiveness of topical antimicrobials (topical ointments/meds used) |
|
|
Term
| purpose of debridement: improve |
|
Definition
| bactericidal activity of leukocytes (body's own defense) |
|
|
Term
| purpose of debridement: shorten |
|
Definition
|
|
Term
| purpose of debridement: eliminate |
|
Definition
| any physical barrier to wound healing (foreign material) |
|
|
Term
| types of wound debridement (2) |
|
Definition
|
|
Term
| types of selective debridement |
|
Definition
| autolytic, chemical/enzymatic, sharp |
|
|
Term
| what does sharp debridement involve |
|
Definition
| use of forceps, scissor, or scalpel to selectively remove material from wound |
|
|
Term
| what does chemical/enzymatic debridement involve? |
|
Definition
| use of topical exogenous enzyme to remove devitalized tissue |
|
|
Term
| autolytic debridement involevs what |
|
Definition
| applying a moisture retentive dressing for several days to use the body's own enzymes to digest necrotic tissue |
|
|
Term
| Non-selective methods of debridment (3) |
|
Definition
| surgical, mechanical, mechanical biological |
|
|
Term
|
Definition
| use of scalpels, scissors or lasers in a surgical environment |
|
|
Term
|
Definition
| use of force via dressings (wet to dry), scrubbing, and cleansing |
|
|
Term
| mechanical biological debridement |
|
Definition
|
|
Term
| purpose of moisture retentive dressing |
|
Definition
| allow moisture to stay in teh wound to prevent drying out |
|
|
Term
| moisture retentive dressings allow for what |
|
Definition
|
|
Term
| moisture retentive dressings faciliate what |
|
Definition
| granulation and epithelialization |
|
|
Term
| moisture retentive dressings does what to rate of infections |
|
Definition
|
|
Term
| how logn do moisture retentive dressing stay in place |
|
Definition
|
|
Term
| most permeable and non-occlusive dressing |
|
Definition
|
|
Term
| most impermeable and occlusive dressings |
|
Definition
|
|
Term
| permeable/non occlusive dressing to most occlusive/impermeable (9) |
|
Definition
| gauze, calcium alginates, absortive fillers, impregnated gauze, transparent film, foam dressings, silver dressings, hydrogels (liquid or sheet), hydrocolloids |
|
|
Term
| dressings from least amount of absorption to most (8) |
|
Definition
| gauze, transparent film, hydrogels (liquid or sheet), hydrocolloids, silver dressings, foam dressings, calcium alginates, absorptive fillers |
|
|
Term
|
Definition
| low cost, can be used with other dressings, provides cushion |
|
|
Term
| disadvantages of gauze (4) |
|
Definition
| adheres to wound bed, high infection rate, may leave particles in wound bed, highly permeable |
|
|
Term
| advantages of transparent films (4) |
|
Definition
| mimics skin's semipermeability, autolytic debridement, stays in place 3-7 days, reduce friction |
|
|
Term
| disadantages of transparent films (3) |
|
Definition
| can't be used with moderate or high exudate, shouldn't be used with infected wounds, shouldn't be used with large or very irregular wounds |
|
|
Term
| (4) advantages of hydrogels |
|
Definition
| retain moisture, allows autolytic debridement, decreases pressure, non-or minimally adherent |
|
|
Term
| 4 disadvantages of hydrogels |
|
Definition
| may dehydrate, can't be used with mod/high exudate levels, shouldn't be used with infected wounds, usually need another dressing over top |
|
|
Term
| 4 advantages of hydrocolloids |
|
Definition
| allows autolytic debridement, retains moisture, impermeable to body fluids, provide moderate absorption |
|
|
Term
| disadvantages of hydrocolloids (3) |
|
Definition
| leaves a residue in wound bed, may cause hypergranulaiton in some areas, shouldn't be used with infected wounds |
|
|
Term
| advantages of foam dressings (5) |
|
Definition
| retain moisture, allow autolytic debridement, provide thermal insulation, may provide cushioning, absorbs moderate to high amounts of exudate |
|
|
Term
| disadvantage of foam dressings (2) |
|
Definition
| should not be used with dry wounds, needs to be changed daily if wounds are infected |
|
|
Term
| 5 advantages of alginates |
|
Definition
| highly absorbent, allows autolytic debridement, can be used with infected wounds, biocompatible, nonadherent |
|
|
Term
| 2 disadvantages of alginates |
|
Definition
| requires another dressing on top, do not use with dry wounds |
|
|
Term
| 3 advantages of absorptive fillers |
|
Definition
| highly absorbent, allows autolytic debridement, can be used wtih infected wounds |
|
|
Term
| 2 disadvantages of absorptive fillers |
|
Definition
| require another ressing on top, do not used with dry wounds |
|
|
