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134 Cards in this Set

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capillaries of the skin are concentrated __

superficially

name the layer of the epidermis from deep to superficial

stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, stratum corneum

where does cellular division in teh epidermis take place?

stratum basale

the __ layer of the epidermis is made of dead skin cells which are filled with keratin and resistant to temperature, pH, enzymatic digestion, and invasion by foreign particles

stratum corneum

what happens to cells as they move from the stratum basale to the stratum corneum?

cells become filled with waxy keratin and die as they move outward. they are used for protection and preventing water loss

what is teh basement membrane?

acellular layer that separates the epidermis from the dermis



is an interface between epidermis and dermis


basement membrane

structure in teh basement membrane that resists shear and has minimal regeneration

rete pegs and dermal papillae

what are the living cells in teh basement membrane?

melanocytes, merkel cells, langerhans cells

cells that produce melanin, located in teh stratum basale

melanocytes

mechanoreceptors that are embedded int eh stratum basale

merkel cells

immune cells in teh basement membrane which are dendritic cell which specializes in capturing foreign particles and presenting them to T cells

langerhans cells

the vascular layer of the skin with blood vessels and lypmphatics present

dermis

the dermis is made of primarily __ and is mostly __ with they primary cell type being __

connective tissue, acellular, fibrolast

the upper layer of the dermis forms the __, protrusions into the epidermis

dermal papillae

what two kinds of proteins are the primary structual proteins of the dermis (provides tensil strength)

collagen type I and II

what two cells are found in the dermis layer?

macrophages and lymphocytes

what are the three main differences between teh two layers of teh dermis?

papillary layer: superficial, loose collagen bundles, vascular eminences rise into epidermis



reticular layer: deep, dense collagen bundles, merges with hypodermis

skin layer made up of loose connective tissue taht supports the skin. includes adipocytes, fibroblasts, and macrophages



much of the bodies fat is stored in this layer

hypodermis

deep source of epidermal cells (lined by stratum basale)



no new units are formed after birth



nails, hair, sebaceous glands, and sweat glands

epidermal appendages

where are sensory nerve receptors located?

in teh epidermis and dermis

how does the skin provide protection from bacteria and viruses

T cells, macrophages, kertain outer layer

how does teh skin provide from mechanical or chemical trauma?

keratin keeps chemical out




dermal papillae and rete pegs protect against mechanical trauma

how does teh skin protect against the loss of fluid?

keratine

explain the cellular process of tissue healing

inflammatory phase: days 1-6



proliferative phase: days 3-20



maturation/remodling phase: day 9-up to 2 years

are the phases of tissue healing distinct and exact?

NO

what are the four manifestations of inflammation?

warmth and redness, welling/edema, pain, loss of function

what causes warmth and redness during inflammation?

vasodilation and increased blood flow to the area (causes swelling)

what causes swelling/edema during inflammation?

increased vascular permiablity and blockage of lymphatic and venous drainage (causes pain)

what causes pain during inflammation?

physical pressure and chemical stimulation of pain receptors

what causes loss of function from inflammation

pain and swelling

what occurs during the inflammatory phase of tissue repair?

tissue injury-->platelet activation-->activation of clotting cascade-->complement cascade-->release of chemicals that:




increase vascular permiability and vasodilation, promote growth and migration of cells for tissue repair, recruit neutrophils, THEN macrophages

immune cells that are one size fits all. respond to all immune events

neutrophils

immune cells that eat up dead tissue

macrophages

a defense against infections and bridge between tissue injury and new cell growth/tissue healing

inflammation

what is the most important stage in wound health

inflammation

the stage of inflammation that is dominated by neutrophils with the goal of protecting against invading bacteria

early inflammation

stage of inflammation that is dominated by macrophages which release chemicals stimulating tissue repair. macrophages are more effective at tissue debridement and stimulate production of vascular and granulation tissue

late inflamamtion

what cells degrade non-viable tissue and participate in neovacularization?

macrophages

that cells perform neovascularization (capillary formation)?

endothelial cells

what cells are involved in collagen/extracellular matrix production?

fibroblasts

what cells are involved in wound contracture?

myofibroblasts

what cells are involved in epithelialization

epithelial cells (basal epidermal cells)

macrophages __ neovascularization

stimulate

when epithlial cells on teh surace of the skin grow over the top of the wound

epithelialization

why do you need neovacularization?

there must be adequate O2 t generate healthy extracellular matrix/granulation tissue and allow re-epithelialization

the connective tissue substance that provides a structure for cell migration via contact guidance and a supporting matrix. it is vascularized and is free of tissue debris, making a appropriate environment for cellular growth

extracellular matrix

how is the extracellular matrix produced

macrophages remove tissue debris and secrete factors which stimulate the fibroblast to proliferate, migrate and produce teh matrix. it consists of collagen type III and I (III mainly)

what happens in the proliferative phase?

wound contracture: fibroblasts differentiate into myofibrolasts



myofibroblasts can stimulate wound "contraction" via intracellular microfilaments containing actin

what three things happen during the epithelialization stage of tissue repair

epidermal cells on teh edge of teh wound proliferates



cells disconnect from teh basement membrane to allow migration



the epidermal cells migrate across teh extracelluar matrix of teh wound from periphery toward teh center


in epithelialization, the presence of non-viable tissue, like eschar, or a scarb will __ cell growth

impede

where do epidermal cells come from?

stem cells

what 4 things occur during the maturation and remodeling phase as the extracellular matrix matures?

increase in collagen type I vs III as type I is stronger



fibers align to increase the tensile strength of the scar, decrease the size of teh scar and softens the tissue



collagen turnover occurs, balancing collagen synthesis and lysis



new collagen is laid down along lines of stress to increase tensile strength of the scar

how long does the maturation/remodeling phase last?

day 9 on

new tissue after maturation and remodeling phase is prone to __

injury

a scar that is red, raised, and fibrous, but stays within the confines of teh original wound

hypertrophic scar

a scar that is similar in character to a hypertorphic scar but it extends beyond the boundry of the original wound

keloid scar

when healing connective tissue, __ is critical to maintain strength of tissues

alignment of collagen

with alignemtn of collagen, fibers align along __

lines of stress

type of wound healing done with sutrue wound edges

primary closure/healing by primary intention

type of healing for open, large full-thickness wounds

secondary closure/healing by secondary intention

type of wound healing used if a wound is heavily contaminated or at risk for infection, it is left open for a period of time and sutured later

delayed primary closure/healing by tertiary intention

what happens to a wound if only the epidermis is injured?

epithlialization (epithelial cells can come from outer edge and from hair follicles)

what happens if teh dermis is injured?

granulation and contraction of the wound

skin tears, abrasions, tape damage, bilisters, dermatitis, and donor sites are all __ wounds

partial thickness wounds

lower extremity ulcers, surgical wounds, abscess formation, and pressure ulces are __ wounds

full thickness wounds

what are the three functions of the immune system?

host defense, tissue clearance, tissue repair

the primary function of the immune system is to defend against foreign pathogens such as bacteria and viruses

host defense

how does the skin help with thermoregulation?

sweat glands, superficial capillaries, fat from hypodermis

what is the difference between an acute and chronic wound?

acute: induced by surgery or surgery in otherwise healthy people



chronic wounds: wounds induced by varying causes whose progression is affected b/c of underlying conditions

what are the four major cateogories of deterrents to expedient wound healing?

characteristics of the wound itself



local factors within the wounded area



systemic factors related to the individual with the open wound



inappropriate wound managment

what are 8 characteristics of wounds that affect wound healing?

mechanism of onset, time of onset, wound location, wound dimensions, temperature, wound hydration, necrotic tissue/foreign bodies, and infection

how can mechanism of onset affect wound healing?

surgical and most acute wounds have less tissue damage and heal rather quickly. insidious/chronic wounds usually have underlying pathology (arterial disease) which deter healing

how can time since onset affect wound healing?

time of onset can be used to predict acute wound healing but not chronic.

what are four instances where wound location affects healing?

areas of decreased vacularity heal more slowly (malleoli vs head and neck)



wounds over bony prominences like greater trochanters heal slower b/c of increased tissue tension



wounds in areas of fewer epidermal appendiges resurface slower than others



wounds where skin is thicker heal slower b/c of more tissue to rebuild

__ wounds heal slower than __ wounds which heal slower than __ wounds

circular, square/rectangular, linear

what is the optimal temp a wound should be kept at and why does this encourage healing?

37-38 celcius (dilates vasculature, tissues less vulnerable to infection and O2 is increased)

a dry wound progesses through the phases of inflammation more __ than a moist wound

slowly

why do dry wounds heal slower than hydrated ones?

drying slows cell migration by increasing the distance they have to travel. it requires more enzyme production to break down the dried crust

exposed wounds are more __ than covered wounds

painful

when a wound is hydrated, the fluids it produces stimulate __, induce __ and cause __

collagen synthesis, angiogenesis, wound contracture

what happens if a wound is wet?

the peri-wound will become macerated making the skin more fragile and possibly increasing the size of the wound

how does necrotic tissue or the presence of foriegn bodies affect wound healing?

epithelial cells can only migrate over viable tissue. dead tissue provides food for microbes encouraging infection

the invasion and multiplication of microorganisms in body tissues

infection

the presensce of microbes

colonization

does colonizaiton imply that a wound is infected? why?

NO, b/c some are normal fauna

explain how infection slows wound healing in chronic wounds

microbes compete with wound tissues for O2 and energy. also secrete cytotoxic substances

when a wound considered "infected"

10^5 microbes/gram of tissue

what are three major changes in chronic wounds that cause them to heal slower than acute wounds?

cells are senescent (are metabolically active but do everything else slower)



have increased levels of inflammatory mediators leading to breakdown of extracellular matrix and inhibits granulation tissue formation



have a greater bioburden than acute wounds

what are three local factors that affect wound healing?

circulation, sensation, and mechanical stress

is a pulse a good indicator of whether or not a wound has proper circulation?

NO! macrocirculation can be fine but microcirculation close to the wound bed can be impaired

conditions that promote a __ response can affect wound healing by impairing circulation

sympathetic

what are four causes of impaired circulation?

imapired macro/micro circulation



cold



fear



pain

how do sensation deficits affect wound healing?

if a pt can't sense tissue damage they can cause worse damage or not seek necessary treatment b/c of lack of pain

__ like pressure, shear, friction, edema, or tension on wound edges all deter wound healing

mechanical stresses

age__ wound healing

decreases

what are 5 systemic factors affecting wound healing?

age, inadequate nutrition, comorbidities, medication, behavioral risk taking

what is one explanation that inadequate nutrition causes slowed wound healing?

if cells don't have carbs to burn they use proteins which would otherwise be used in healing.

which is more important to wound healing: a pt recent food intake or what they've consumed in the last few weeks?

their recent food intake

why are pt's with wounds more prone to develop malnutirtion?

the wound is catabolic (needs lots of energy)

what are 5 goals for wound managment ?

control wound exudate



deal with infection



protect skin



heal pressure ulcers



address pt comfort

what are three things that arterial insufficincy causes in wounds?

decresased O2



chronic wounds



increased susceptibiltiy to infection

what are three things that venous insufficiency cuase?

edema



fibrin in teh tissue



high risk for developing infection

how do steroids affect wound healing?

decrease collagen synthesis



suppress immune system

how do NSAIDS affect wound healing?

vasconstriction, suppress inflammation and collagen synthesis

how do chemo drugs affect wound healing?

interfere with cell proliferation



prolong inflammation



inhibit protein and collagen synthesis

how do antineoplastic drugs affect wound healing?

fibroblast production

how does diabetes affect wound healing?

accelerated atherosclerosis (decreased circulation)



neuropathy



abnormal collagen synthesis

how do vascular diseases affect wound healing?

decreased blood supply and tissue perfusion

how do immunicompromising diseases affect wound healing?

increased infection, affects phagocytosis

how do renal dysfunctin diseases affect wound healing?

granulation and fibroblasts

how does lymphedema affect wound healing

delays it

changes in cellular activity, decreased vascularization and atrophy of the dermis, slower healing, decreased synthesis of collagen and fibroblast production, and a decreased inflammatory response are all factors in __ that affect wound healing

age

how does alcohol abuse affect wound healing?

malnutrition



increased risk of injury



delayed medical care

how does smoking affect wound care?

vasconstriction



increased platelet aggregation



decreased O2 b/c of CO

stress/depression or anxiety all __ wound healing

decrease

__ is a nonselective debridement which can damage healthy tissue

wet to dry

__ dressings will cause dehydration of the wound

dry gauze

what is a primary goal of wound dressing?

to maintain a moist wound bed

__, __, and __ will perpetuate and initiate presure ulcers and neuropathic ulcers

pressure, shear, friction

why does edema delay wound healing?

decreased tissue perfusion due to decreased blood flow

decreased mobility secondary to pain can cause __

DVT, pressure ulcers

what are the four parts to a wound evaluation?

history, subjective exam, objective exam, assessment

what are the three parts of a history?

general history, previous history, social history

what 5 questions would you ask during a general history?

age, sex, occupation



when did teh wound develop



how did it develop



psychological, cultural, and economic that impact the pt



what the wound means to the pt

diabetes, PVD< HTN, CHF, medications, allergies, and prevous wound hisotry and tratements would all be part of the __ part of a wound eval

previous history

what four things should you ask in a social history?

smoker?, dietary intake?, alcohol use, describe a usual day

what three things should you ask in a subjective exam?

symptoms (pain level and location, when it occurs, consequences, characteristics)



where its located



behavior of symptoms

what are four things you would do in teh objective part of the exam

risk assessment tools, wound calssification, observations, clinical measurements

what are three things to look for for wound classificatoin during teh objective part of the exam

partial or full thickness



color



4 stages system for pressure ulcers

what are 5 observations to make during teh objective part of the exam

skin color, texture of the skin, temperature of the skin, skin integrity, foreign debris or necrotic tissue

what are 6 clinical measurements to make during the objective part of the exam?

clutre, location, size/depth, drainage, temperature, and girth

what are three tests to assess the venous system?

trendelenburg, doppler US, homans sign (DVT)

what are four steps to assessment for wound care

determine accurate wound diagnosis



short term/long term goals



determine plan of care



make recomendations for treatment