The Skin: Structure, Function, and Wound Healing, Exams of Nursing

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Wound Care updated Exam 1 (1st half) Skin Facts - answer ✅✅-Size: 2 square meters -Weight: 15% TBW -Recieves 1/3 of total circulation. -Largest Organ Skin Functions - answer ✅✅-Thermoregulation-Protection-Immunity-Sensation-Metabolism -Communication Epidermal Appendages (Skin) - answer ✅✅-Nails-Hair Follicles-Sweat glands Epidermis (Layers--superficial to deep) - answer ✅✅-Stratum corneum-stratum lucidum-stratum granulosumstratum spinosum-stratum basle Epidermis - answer ✅✅-Outermost layer-uniform thickness (except palms/soles = 0.06-0.6 mm)-Stratified squamos epithelial cells ( 20 cells thick; Very young/old have only 12)--> leads to more wounds-5 Layers -Thick collagen fibers-Cutaneous blood vessels Important Dermal Cells - answer ✅✅-Fibroblasts-Macrophages-Mast Cells-Nerve Cells-Epidermal Appendages Fibroblasts (dermal cells) - answer ✅✅-producecollage and elastin-important for elasticity in would healing Macrophages and WBC (dermal cells) - answer ✅✅-Regulate Wound Repair process (fight infection)-Phagocytize bacteria-break down damage tissue-synthesize collagenase and elastase (enzymesthat break down dead tissue) Mast Cells (dermal cells) - answer ✅✅-produce histamine -->causes vasodialation-Activate inflammatory response Hypodermis - answer ✅✅-A subcutaneous layer of loose connective tissue containing a varying number of fat cells: -Adipose Tissue-Fascia-Lymphatic Vessels Adipose Tissue - answer ✅✅-Loose connective tissue-holds fat-Energy reserve, protection, thermoregulation Fascia - answer ✅✅-Fibrous connective tissue-surrounds, separates, facilitates movement Lymphatic Vessels - answer ✅✅-A vessel that conveys lymph. Age Related Changes - answer ✅✅-NEONATAL (term delivery + 2 weeks) -Very permeable -caution with topical meds -Infants (After 42 weeks) -Skin, tears, occipital skin breakdown Partial Thickness - answer ✅✅-confined to epidermis and superficial (papillary) dermis Full Thickenss - answer ✅✅-Total loss of skin layers and often include deeper tissues (may see bone) Acute Wound - answer ✅✅-Occurs suddenly, predictable repair process, durable closure Chronic Wound - answer ✅✅-Unpredictable repair process Angiogenesis - answer ✅✅-formation of new blood vessels-complex process-inflammatory cells secrete angiogenic substances-endothelial cells adjacent to wound create pathways for new vessels-New endothelial cells project "sprouts" into wound bed --develop capillary tubes. **Does not heal linearly (equally) Granulation Tissue - answer ✅✅-Composed of capillary loops and extracellular matrix (new connective tissue)-Contains fibroblasts and inflammatory cells-Fibroblasts are the ONLY cells that make collage ***-Beefy red color ***Never do we to dry dressing*** Wound Contraction - answer ✅✅-Myofibroblastspull wound edges together-speed varies with size and shape of wound-Epithelialization Epithelialization - answer ✅✅-Epithelial cells migrate across wound bed-Need to keep wound edges open-If dry, epethelial cells stop or move to moisture Wound Maturation - answer ✅✅-When epithelial cells "meet in middle" they stop moving laterally-Begin growing upward like normal dermal cells-Collagen fibers mature-Can force collagen fibers to realign (Tension Theory)-Scar Tissue = 80% of original tissue strength Wound Closure by Primary Intention - answer ✅✅-Surgery and minor cuts-wound clean so shorter inflammatory phase-Epithelialization begins within 24 hrs-"Healing Ridge" should be palpable by 5-9 days post-op Secondary Intention - answer ✅✅-When wound edges cant be approximated-Heals by granulation-No homeostasis, so longer process-No release of growth factors by clot breakdown-Surgical debridement can jump start healing Tertiary Intention - answer ✅✅-AKA delayed primary close-Delay of closure due to: Infection, Patient too ill/unstable Abnormal Inflammation - answer ✅✅-Absence Inflammation Contractures - answer ✅✅-Shortening of scars ie: burns-more problematic over joints-PREVENTION IS CRUCIAL Dehiscene - answer ✅✅-Seperation of wound edges -Factors Affecting Wound Healing - answer ✅✅-Wound Characteristics-Local Factors-Systematic Factors Wound Characteristics - answer ✅✅-Onset: Rapid or Insidous-Duration: longer its there harder to heal-Location: Related to motion, blood supply, and pressure-Size: bigger they are the slower they heal-Temperature: Faster healing with normal temperature -Hydration: MOIST WOUND BED is critical to healing-Necrotic Tissue: must be removed-Infection- prolongs inflammation and delays healing Local Factors - answer ✅✅-Oxygenation: requires circulation -Inflammation and proliferation phases require most O2 -Fibroblasts need O2 -may need vascular consult -Sensation: -Peripheral neuropathy a problem -So patient identifies and protects wound -Mechanical Stress: -Friction -Shear (internal against internal) -Tension on wound edges -edema Systematic Factors (Age) - answer ✅✅-Delayed in elderly-Decreased collagen synthesis-Decreased inflammatory response-Decreased blood supply to skin Systematic Factors (Nutrtion) - answer ✅✅-Protein-Carbs-Fats-Ascrobic Acid-Iron-Zinc Systematic Factors (Comorbidities) - answer ✅✅-Diabetes mellitus -Blood sugar >180 makes WBCs ineffective -compromises fibroblast activity -reduces growth factors and impairs collagen sythesis -PO, IV, Enteral tube -Barriers: Unconscious, need greater than person can tolerate, cancer, stroke Protein - answer ✅✅-Require collagen synthesisand immune function-can be lost in wound drainage-Low = alters osmotic pressure (incr interstial fluid, O2 can diffuse through fluid well)-Edema can put pressure on blood vessels and restrict blood flow Carbohydrates - answer ✅✅-Provide energy for tissue maintenance and repair-Can help prevent use of protein stores for energy (protein sparing)-Glucose essential for phagocytosis Fats - answer ✅✅-Energy source (protein sparing)-Essential for adequate fat-soluable vitamins -helps with thermoregulation/insulation-essential for healthy cell membranes Additional Nutrients Needed - answer ✅✅-Vitamis: A, C, K, B complex, E-Minerals:zinc, iron, copper, Mg, Ca, Phosphorus Vitamin A - answer ✅✅-Maintains skin and epithelial tissue-Helps with collagen sythesis, granulation, epithelialization-Others:-Increase tensile strength of wound tissue-reduce wound healing problems when patient on steroids-enhance wound healing in diabetic Vitamin C - answer ✅✅-Essential to build and maintain tissue-Facilitates iron absorption-Essential for collagen synthesis others:-Activates WBCs-Enhance WBCs ability to migrate to wound-Limit damaging effect of free radicals Vitamin K - answer ✅✅-Essential for blood clotting Vitamin B Complex - answer ✅✅-essential for normal immune function and energy metabolism Vitamin E - answer ✅✅-Decreases inflammatoryphase of wound healing-Decreases platelet adhesion Zinc - answer ✅✅-Critical for normal wound repair (too much may impair copper function)-Collagen and protein synthesis-Immune function-Supplementation should be considered if levellow or chronically poorly nourished -Blood sugar(70-99) - Increased risk of ulceration and delayed healing Caloric Need - answer ✅✅-Convert wt to kg-Multiply wt x 30-35 (varies due to age and activity level)-Gives you caloric intake for wound healing. **this is shortcut should refer to RD**NOT all calories are created equal! Nutritional Needs (protein) - answer ✅✅-convert lbs to kg-multiply weight by 1.2 - 1.5-1.5 preferable but MUST confirm adequate fluid needs met and renal function. Nutritional Needs (Fluid) - answer ✅✅- kg x 30-need more fluid if larger losses (fever, large draining wound, vomiting, diarrhea) Clinical Observations - answer ✅✅-Muscle Wasting-Dry thin hair-Dry Flaky Skin-Dry Mucous Membranes-Delayed wound healing Supplements - answer ✅✅-Most clinician recommend Multi vit (2011 contradicts this)-Vitamin C 500-2000 mg/day (only for heavily draining wounds)-Zinc replacement controversial -excess = upset GI -if defecit give 220 daily for 1-2 weeks or untilnormal level -found in meat, milk, eggs -Oxandrin (oxandrolone)- anabolic steroid -if pt lost > 10% LBM -many contraindications so be cautious Other options for Oral Intake - answer ✅✅-Nutritional supplements taken orally-Boost, Ensure, Carantion complete-High calorie, nutrient dense snack Obese Patients - answer ✅✅- 2/3 of US adults obese or overweight-consider risk vs. benefits of weight loss if pt has wound-NO evidence guidelines for nutritional needs of obese pt with pressure ulcer-Require adequate calories, protein, fluids, nutrients-Goal is to promote healing-Monitor overall skin integrity Calculation of Nutritional Needs for Obese Patients - answer ✅✅-Limited research for guidelines-Protein needs vary: -Renal status -presence of ulcer or wound -System Review-Test and Measures (wound characteristics; condition of surrounding skin)-Pt Diagnosis-Prognosis-Intervention-Outcomes History - answer ✅✅-Demographics-Social History-Living Enviroment-Functional Status/Activity Level-Health Behaviors-Medical and Surgical History-Family History-Medications-Allergies (latex sulfa, adhesives)-Clinical Tests History cont. - answer ✅✅-Current wound event(when/how, pain level, does pain change, progress)-Previous wounds (when/how, prior treatment,prior diagnostic tests/results) System Review (Cardiopulmonary) - answer ✅✅-HR-BP-RR-Edema-Peripheral pulses-pulse oximetry Systems Review (Musculoskeletal) - answer ✅✅-posture-ROM-Strength Systems Review (Neuromuscular) - answer ✅✅-Mobility and gait System Review (Gastrointestinal and Urogenital) - answer ✅✅-Nutrition-Incontinece-Signs of DM or UTI Wound Characteristics Locations - answer ✅✅-wound location may provide useful clues to etiology of wound -Bony prominence = pressure ulcer-Tibia, distal toes = arterial wound-Medial lower leg (Gaiter distribution) = Venous Wound Characteristics Size (Direct Measurement) - answer ✅✅-Simplest measure is length, width, depth-if done consistency is often considered adequate for general use-Not reliable enough for studies-Reliability decreases with increasing size-Must take care not to cross contaminate (disposable measures best) Wound Size: Volumetric Measurement - answer ✅✅-Saline instillation - SD between 9 - 18%-Alginate moulds - SD 5 -16%-Time consuming-Misleading Calculations-Cannot be used to measure wounds that extend into fascial planes or body cavities. Wound Size: Tunneling - answer ✅✅-Narrow passage "tunnel" created by separation of facial planes **Measure with a probe, use clock terms to identify position Wound Size: Undermining - answer ✅✅Tissue under wound edge becomes eroded leading to a large wound with a small opening. **Measure with a probe, use clock terms to identify position Granulation - answer ✅✅-Red, Firm, pebbled.-Friability may indicate infection. Fibrin - answer ✅✅-Yellow and Firm.-Represents collagen in the wound bed. Slough - answer ✅✅-Yellow to gray-green and loose.-May represent necrotic fascia. Eschar - answer ✅✅-Black, soft and wet or hardand dry-Necrotic Tissue Wound Charcteristic: Wound Edge - answer ✅✅-Presence or absence of attached edge with advancing border of epithelium-Evidence of epithelialization, scarring or pigment changes.-Hyperkeratosis at edges-Presence or absence of erythema and/or induration -Presence or absence of maceration Drainage Quantity - answer ✅✅-Dressing not absorptive enough (may appear to be draining more heavily than actually is) -Dressing too absorptive or changed recently (may appear to be draining less than actually is) -none (least drainage)-minimal-moderate-Copious (most drainage) Assess appearance of dressing prior to Removal - answer ✅✅-Strike through-Leakage-Is dressing intact Assess dressing at removal - answer ✅✅-Exudate -Amount -Psuedomonas - blue green drainage with a "sick sweet" smell-Proteus - ammonia smell Condition of Surrounding Skin (Structure and Quality) - answer ✅✅-Anyhydrous or macerated-Tugor-Callus-Rashes-Blisters Condition of Surrounding Skin (Color) - answer ✅✅-Blanchable or Non Blanchable Erythema-Hyperpigmentation-Edema-Inflammation, induration-Pitting Edema Condition of Surrounding Skin (others) - answer ✅✅-temperature-circulation -sensation Wound Characteristics: PAIN - answer ✅✅-Increasing pain could mean deterioration of wound and possible infection. Pain Scale: 'Zero to ten' Scale = standard rating scale Common Questions that should be asked - answer ✅✅-Is wound painful?-If the wound is painful, does anything reduce the pain?-Does anything make the pain worse? Physical Therapy Diagnosis: Integumentary Preferred Practice Patterns - answer ✅✅-Pattern A: Prevention/Risk Factor Reduction -Pattern B: with superficial skin involvement -Pattern C: partial-thickness involvement and scar formation -Patter D: full thickness skin involvement and scar formation -Pattern E: full thickness skin extending into fascia, muscle, or bone and scar formation Prognosis - answer ✅✅-Percent change in wound surface are best predictor of healing outcome.-Wounds that show 20-40% reduction in surface over 2-4 weeks are more like to heal by 12 weeks. R = Reevaluate - answer ✅✅-Regularly reevaluate wound and wounded pt-Treated wound should make consistent progress within 2 weeks-failure to make progress should prompt search for explanation and alternative interventions. -Warm-Edematous (evaluate potential causes)-Drainage (amount, consistency, color, odor) Technique for Culture - answer ✅✅-Gold Standard is tissue biopsy ***-Swab culture more common (levine technique) -debride/rinse wound -moisten swab w saline without preservative -rotate swab 1 square cm w enough pressure to get fluid -transport to lab Osteomyelitis - answer ✅✅-inflammation of bone or bone marrow due to infection.-suspect if: -wound healing delayed, with or without systemic infection signs-Bone biopsy gold standard*** (usually use MRI) -Exposure of bone or ability to probe bone has positive predictive value of 89% Local Treatment of Wound Infection - answer ✅✅-Clean wound bed with NS or sterile water-4-15 psi pressure to dislodge bacteria-commerical "cleansers" often cytotoxic to fibroblasts and leukocytes-debride wound bed Topical Therapy - answer ✅✅-Antiseptic often nonselective-Restrict use to 1-2 weeks for specific indications(Acetic acid, Betadine, Chlorhexidine, Dakin's solustion, Hydrogen peroxide) Topical Antibiotics - answer ✅✅-Select based onC & S reports-Higher concentration at wound bed-Limited systematic absorption and toxicity-Few clinical trial to prove efficacy (bacitracin, sulfamylon, neomycin (can lead to sensitivity to amnioglycosides) Topical Elemental Antimicrobials - answer ✅✅-Use judiciously for 2-4 weeks -Elemental Iodine (absorbs bacteria as it releases iodine) -Iodosorb -non-toxic to fibroblasts -May sting when applied -Sliver -Used since ancient Greece -Cream or sustained release incorporated intodressing -Broad-Spectrum antimicrobial effects -Silver is released in moist enviroment Medical Honey - answer ✅✅-Osomtic effect dueto high sugar content TIME principle of wound Bed Preperation - answer ✅✅T - Non vital or insufficient tissueI - InfectionM - Moisture imbalanceE Edge of wound and epithelialization **to properly organize the principles of wound preperation Purpose of Debridement - answer ✅✅-Reduces bacterial contamination (bioburden) and risk of infection-Topical wound management can be more effective-Improves bactericidal activity of leukocytes-shortens inflammatory response-Decreases the energy required for wound healing-Provides visualization of wound bed by eliminating physical barrier-Decreases wound odor Why Debride? - answer ✅✅-Debridement of necrotic tissue is essential to allow normal healing -Epithelial cells dont migrage across dead tissue Indications for Debridement (Essential component of management when:) - answer ✅✅-Wounds infected OR-Goal is to repair Indications for Debridement (Red-Yellow-Blacksystem) - answer ✅✅-Red: Granulation (protect, maintain moist wound bed)-Yellow: Slough (absorb drainage, debride)-Black: eschar (debride) Indications for Debridement (calluses) - answer ✅✅-Debride to reduce localized pressures -Especially plantar surfact of foot Indications for Debridement (Blisters) - answer ✅✅-Large fluid filled blisters -Blisters over joints-Burn blisters (fluid in blisters alters bactericidal activity of neutrophils and inhibits fibronolysis. Contraindications to Debridement - answer ✅✅-Red, granular wound bed-Heel Ulcers with dry eschar-Urgent need for surgical debridement (life/limb-sparing surgery)-Debridement of muscle, tendon, ligament, capsule, fascia, bone, nerve, vessels.-Gangrenous tissue present-Electrical burns or full thickness burns require early surgical excision Prior to Debridement Assess: - answer ✅✅-Thorough History (social, occupational, functional status, Meds)-Lab Work (albumin,prealbumin,CBC,Pro time,INR, Creatine, BUN,glucose)-Wound assessment (Undermining, Tunneling, Sinus Tract, fistula) -Surgical -Mechanical Surgical Debridement - answer ✅✅-Controlled setting performed by physician or podiatrist-Best for: -Full thickness wounds of bone, joints -infected necrotic tissue -Large amounts of necrotic tissue with undermining or tunneling-Fast and agressive-Patient status (may not be possible due to anesthesia) Sharp Debridement (Inidcations) - answer ✅✅-Use scalpel, forceps, scissors to remove necrotic tissue-Indications: -Loose avascular tissue -Eschar too thick for enzymatic or autolytic debridement Sharp Debridement (Contraindications) - answer ✅✅-Systematic infection-many systematic illnesses-Dark hole unable to visualize Sharp Debridement (Criteria) - answer ✅✅-must be covered by state practice act-need institutional clearance-Wound is infected-Patient clots normally-Eschar loose enough to see where you're going-Evidence of adequate circulation to ulcer area(check ABI with leg ulcers) Sharp (Keys to knowing when to STOP) - answer ✅✅-Impending exposure of tendon, bone, nerve-Excessive bleeding-Get nervous or unsure-Holes you didnt expect or cant see into -presence of unexpected gross infection Sharp Procedure - answer ✅✅-Lift eschar with forceps or clamp-Cut into it with scissors/scalpel-Remove tissue in thin layers/small pieces( hold scalpel parallel to tissue being debrided)-Pain/bleeding can determine stopping point-Usually 30 min or less Serial Instrumental Debridement - answer ✅✅-Uses forceps and scissors to remove LOOSELY necrotic tissue-performed over several visits-Creates minimal bleeding-May require prior tissue preparation (hydrotherapy)-Can be done by PT/PTA Selective Sharp Debridement - answer ✅✅-Usesscissors or scalpel to cut along border of viable and nonviable tissue Procedure/Products (EXUDATIVE WOUND) - answer ✅✅-Absorbent Dressing -Alginate dressings, hydrocolloids, foams, gauze Enzymatic Debridement - answer ✅✅-They're never wrong says Dorothy-Use exogenous enzymatic solutions or ointments to separate necrotic and viable tissue-Selective (wont damage healthy tissue)-Fast acting-Can be done on infected wounds-Allergic response is rare Enzymatic Debridement Disadvantages - answer ✅✅-Expensive-Requires physician prescription-Contraindicated if deep tissues exposed-DO NOT use if wound is being autolytically debrided (need regular irrigation)-DO NOT use in combo with heavy metal ions or cleansers Enzymatic Agents - answer ✅✅-Collagenase Santyl Ointment = only FDA approved-Silver, mercury, lead all decrease activity Enzymatic Debridement Procedure - answer ✅✅-Follow manufacturer's guidelines-Cover with damp gauze dressing OR-Collagenase more effective if covered with nonadherent gauze-Results = 2-3 days-Can be used in patient on abx Mechanical Debridement - answer ✅✅-Nonselective-wet to dry dressings-Scrubbing-Hydrotherapy: -whirlpool -pulsative lavage -wound irrigation Mechanical Debridement (Wet to Dry Dressing) - answer ✅✅-ONLY USE if wound has 100% necrotic tissue-OUCH-Contraindicated if wound bed is granulating-Does NOT promote moist wound healing environment Mechanical Debridement (Wound Scrubbing) -answer ✅✅-wound cleanser contains surfactants to help remove particulates and gauze Cleansing - answer ✅✅-Use of fluids to remove LOOSE adherent material Debridement - answer ✅✅-Enzymatic or sharp dissection process to remove TIGHTLY adherent necrotic material. General Priniciples of Wound Cleansing - answer ✅✅-Start every dressing with wound cleansing neuropathic wounds, pressure ulcers, small burns,surgical or trauma wounds.-Better than whirlpool for venous insufficiency wounds-Used on wounds with undermining or tunneling using a tip to facilitate irrigation of areas. Pulsed Lavage Suction (CONTRAINDICATIONS) - answer ✅✅-Exposed arteries, tendons, nerves, bones, joint capsules-Recent skin grafts or surgical procedures-Body cavities Pulsed Lavage Suction (PRECAUTIONS) - answer ✅✅-Patients taking anticoagulants-Patients who are insensate-Deep Tunnels Pulsed Lavage with Suction (PROCEDURE) - answer ✅✅-To decrease risk of cross contamination: -cover pts IV sites with towel -Patient should wear a mask -pt must wear barrier devices to prevent splash injury-Irrigant should be warmed to 102-106-Suction 60 to 100 mmHg-Use pump pressure of 8-12 psi -lower pressure with tunnels and undermining-Follow facility infection guidelines -disposal of pulse lavage equip -cleaning treatment surface and facility Pulsed Lavage Suction (TREATMENT TIME) - answer ✅✅-Follow debridement guidelines-Recommend that treatment be stopped at 30 min to prevent fatigue Pulsed Lavage Suction (TREATMENT FREQUENCY) - answer ✅✅-May be used as 2x/day in wounds with excessive amount of necrotic tissue (>50%)-As few as 3x/week in granular wounds Pulsed Lavage Suction (Outcome Measures) - answer ✅✅-No controlled clinical trials exist-Per Harriett Loehne expect -decrease necrotic tissue 1 week -increase granular tissue in 2 week -odor and exudate free in 3-7 days -Necrosis free in 2 weeks -progress from chronic inflammatory phase to acute inflammatory phase week 1-Acute to proliferative phase in week 2 Wound Irrigation Systems - answer ✅✅-Maximum safe irrigation pressure = 15 psi -bulb syringe (2 pis) -#19 needle on syringe (8-10 psi) -tume syringe (4 psi) -water pik (low = 6 psi, Med = 35 psi, High = 70 psi)