Podcast
Questions and Answers
In the context of geriatric integumentary health, what specific biophysical change most critically undermines the skin's capacity to withstand shear forces, thereby escalating the risk of traumatic skin injuries?
In the context of geriatric integumentary health, what specific biophysical change most critically undermines the skin's capacity to withstand shear forces, thereby escalating the risk of traumatic skin injuries?
- A significant reduction in the density and activity of eccrine sweat glands, impairing thermoregulatory efficiency and leading to epidermal dehydration.
- Progressive degradation and disorganization of dermal collagen and elastin fibers, resulting in diminished tensile strength and elasticity. (correct)
- Increased melanocyte activity in chronically sun-exposed areas, causing hyperpigmentation and localized epidermal thickening.
- Diminution in the proliferative capacity of epidermal keratinocytes, leading to a reduced epidermal turnover rate.
What specific alteration in dermal microvasculature contributes most significantly to the increased incidence of senile purpura in geriatric patients?
What specific alteration in dermal microvasculature contributes most significantly to the increased incidence of senile purpura in geriatric patients?
- Selective downregulation of vascular endothelial growth factor (VEGF) receptors, leading to impaired angiogenesis.
- Progressive calcification of the tunica media layer in dermal arterioles, leading to reduced vascular elasticity.
- Proliferation of angiofibroblasts within the perivascular space, resulting in diminished capillary compliance.
- Atrophy of the supporting connective tissue and perivascular collagen, resulting in increased capillary fragility. (correct)
In a patient presenting with a lower extremity ulcer, what clinical characteristic most reliably differentiates a neuropathic ulcer from one caused by arterial insufficiency?
In a patient presenting with a lower extremity ulcer, what clinical characteristic most reliably differentiates a neuropathic ulcer from one caused by arterial insufficiency?
- The presence of irregular wound borders and surrounding hyperpigmentation.
- Reduced or absent pedal pulses with concomitant cool skin temperature.
- The presence of a painless ulcer with a surrounding callus formation. (correct)
- Severe pain exacerbated by limb elevation.
What is the MOST SPECIFIC underlying mechanism that connects decreased sebaceous gland activity in aging skin to an increased susceptibility to skin breakdown and infection?
What is the MOST SPECIFIC underlying mechanism that connects decreased sebaceous gland activity in aging skin to an increased susceptibility to skin breakdown and infection?
What cellular mechanism is most directly implicated in the development of hypertrophic nails, frequently observed in the geriatric population?
What cellular mechanism is most directly implicated in the development of hypertrophic nails, frequently observed in the geriatric population?
What is the specific pathophysiological process linking the flattening of epidermal-dermal projections in aging skin to an increased risk of skin tears?
What is the specific pathophysiological process linking the flattening of epidermal-dermal projections in aging skin to an increased risk of skin tears?
What critical molecular process underlies the increased risk of xerosis in aging individuals, and how does this process compromise the skin's barrier function at a biochemical level?
What critical molecular process underlies the increased risk of xerosis in aging individuals, and how does this process compromise the skin's barrier function at a biochemical level?
Which age-related physiological change most directly contributes to the slowed rate of re-epithelialization observed in partial-thickness wounds in older adults?
Which age-related physiological change most directly contributes to the slowed rate of re-epithelialization observed in partial-thickness wounds in older adults?
A patient presents with shiny, hairless skin on their lower extremities, accompanied by distal wounds and weak pedal pulses. What is the MOST LIKELY underlying pathophysiology?
A patient presents with shiny, hairless skin on their lower extremities, accompanied by distal wounds and weak pedal pulses. What is the MOST LIKELY underlying pathophysiology?
An elderly patient is being assessed for pressure ulcer risk using the Braden Scale. Which component of the Braden Scale is MOST directly correlated with the patient's ability to redistribute pressure independently?
An elderly patient is being assessed for pressure ulcer risk using the Braden Scale. Which component of the Braden Scale is MOST directly correlated with the patient's ability to redistribute pressure independently?
In the context of burn injury assessment, what is the MOST CRITICAL clinical factor differentiating a deep partial-thickness burn from a full-thickness burn?
In the context of burn injury assessment, what is the MOST CRITICAL clinical factor differentiating a deep partial-thickness burn from a full-thickness burn?
What is the rationale for limiting the maximum weight one healthcare worker should safely lift to 35 pounds, as per NIOSH guidelines?
What is the rationale for limiting the maximum weight one healthcare worker should safely lift to 35 pounds, as per NIOSH guidelines?
In a patient with suspected arterial insufficiency, what diagnostic finding on Ankle-Brachial Index (ABI) is MOST suggestive of severe peripheral arterial disease?
In a patient with suspected arterial insufficiency, what diagnostic finding on Ankle-Brachial Index (ABI) is MOST suggestive of severe peripheral arterial disease?
An elderly patient presents with a skin tear characterized by complete separation of the skin flap and exposure of the entire wound bed. According to the International Skin Tear Advisory Panel (ISTAP) classification, how should this skin tear be classified?
An elderly patient presents with a skin tear characterized by complete separation of the skin flap and exposure of the entire wound bed. According to the International Skin Tear Advisory Panel (ISTAP) classification, how should this skin tear be classified?
In the context of wound healing in older adults, what is the MOST SIGNIFICANT implication of decreased tensile strength in newly healed wounds?
In the context of wound healing in older adults, what is the MOST SIGNIFICANT implication of decreased tensile strength in newly healed wounds?
What underlying process is most likely responsible for the increased risk of pressure injuries to the skin in patients with a high BMI?
What underlying process is most likely responsible for the increased risk of pressure injuries to the skin in patients with a high BMI?
While caring for a patient in an ICU, what is the most accurate intervention to improve a patient's mobility for a BMAT level of 2?
While caring for a patient in an ICU, what is the most accurate intervention to improve a patient's mobility for a BMAT level of 2?
What specific biochemical alteration in aged dermal fibroblasts leads to a reduction in collagen synthesis, ultimately contributing to decreased skin elasticity and increased vulnerability to injury?
What specific biochemical alteration in aged dermal fibroblasts leads to a reduction in collagen synthesis, ultimately contributing to decreased skin elasticity and increased vulnerability to injury?
A clinician is assessing a patient for frailty using the criteria proposed by Fried. What specific finding BEST supports the determination that an individual meets one of the criteria for frailty?
A clinician is assessing a patient for frailty using the criteria proposed by Fried. What specific finding BEST supports the determination that an individual meets one of the criteria for frailty?
A patient has an unstageable wound. What intervention is the most appropriate at this time?
A patient has an unstageable wound. What intervention is the most appropriate at this time?
In a patient with a neuropathic foot ulcer, what is the MOST IMPORTANT underlying pathophysiological mechanism driving the formation of the ulcer?
In a patient with a neuropathic foot ulcer, what is the MOST IMPORTANT underlying pathophysiological mechanism driving the formation of the ulcer?
A patient is being treated for a burn on their axilla. What is the most important position to prevent contractures?
A patient is being treated for a burn on their axilla. What is the most important position to prevent contractures?
In regards to the SKIN acronym, what does the "S" stand for?
In regards to the SKIN acronym, what does the "S" stand for?
A patient is going to ambulate but had a recent fall. They are BMAT level 3. Which equipment is the best to use?
A patient is going to ambulate but had a recent fall. They are BMAT level 3. Which equipment is the best to use?
What is the most accurate about the definition of frailty?
What is the most accurate about the definition of frailty?
Which statement is the most correct regarding venous wounds?
Which statement is the most correct regarding venous wounds?
The use of a draw sheet serves what purpose?
The use of a draw sheet serves what purpose?
As per the information provided, which lab value is indicative of a good indicator of the effect of nutritional intervention?
As per the information provided, which lab value is indicative of a good indicator of the effect of nutritional intervention?
Which of the following best describes the FRAIL screen?
Which of the following best describes the FRAIL screen?
A clinician is creating a progressive plan of care involving graded exposure to upright after prolonged bed rest. The information provided on progression of mobility, what is the MOST APPROPRIATE clinical plan to implement after sitting edge of bed for PT intervention session(s)?
A clinician is creating a progressive plan of care involving graded exposure to upright after prolonged bed rest. The information provided on progression of mobility, what is the MOST APPROPRIATE clinical plan to implement after sitting edge of bed for PT intervention session(s)?
A clinician must choose the best support to reduce pressure. According to the information, what intervention is the BEST to protect bony prominences?
A clinician must choose the best support to reduce pressure. According to the information, what intervention is the BEST to protect bony prominences?
A patient developed a wound on their lower extremity. The physician believes it is related to arterial insufficiency. Which presentation is typically seen with arterial insufficiency?
A patient developed a wound on their lower extremity. The physician believes it is related to arterial insufficiency. Which presentation is typically seen with arterial insufficiency?
When considering what equipment is acceptable, what statements is the best description in regards to a Hovermatt?
When considering what equipment is acceptable, what statements is the best description in regards to a Hovermatt?
What parameters on chart review are most important?
What parameters on chart review are most important?
What is true of scar maturation?
What is true of scar maturation?
What is lost when someone cannot walk 15 feet due to weak quads?
What is lost when someone cannot walk 15 feet due to weak quads?
If a patient cannot lift against gravity, what level of care is this patient in?
If a patient cannot lift against gravity, what level of care is this patient in?
If someone overinflates a roho, what is the best decision to deflate?
If someone overinflates a roho, what is the best decision to deflate?
In the context of geriatric skin, a decrease in the quantity and activity of sebaceous glands has the MOST DIRECT impact on which of the following biomechanical properties?
In the context of geriatric skin, a decrease in the quantity and activity of sebaceous glands has the MOST DIRECT impact on which of the following biomechanical properties?
An 80-year-old male with a history of peripheral arterial disease (PAD) develops a lower extremity ulcer. Upon examination, the wound is located on the distal aspect of the great toe, exhibits minimal drainage, and has a clearly demarcated border with a necrotic base. The patient reports significant pain, particularly at night. Which pathogenetic mechanism is MOST directly contributing to the recalcitrant nature of this wound?
An 80-year-old male with a history of peripheral arterial disease (PAD) develops a lower extremity ulcer. Upon examination, the wound is located on the distal aspect of the great toe, exhibits minimal drainage, and has a clearly demarcated border with a necrotic base. The patient reports significant pain, particularly at night. Which pathogenetic mechanism is MOST directly contributing to the recalcitrant nature of this wound?
In the International Skin Tear Advisory Panel (ISTAP) classification system, a Type 2 skin tear is defined by which characteristic?
In the International Skin Tear Advisory Panel (ISTAP) classification system, a Type 2 skin tear is defined by which characteristic?
A clinician is assessing an elderly patient with multiple comorbidities for frailty using Fried's criteria. Which of the following findings would provide the STRONGEST evidence supporting a diagnosis of frailty based on the established criteria?
A clinician is assessing an elderly patient with multiple comorbidities for frailty using Fried's criteria. Which of the following findings would provide the STRONGEST evidence supporting a diagnosis of frailty based on the established criteria?
Compared to younger adults, the molecular underpinnings of age-related changes in wound healing result primarily from:
Compared to younger adults, the molecular underpinnings of age-related changes in wound healing result primarily from:
An 85-year-old patient has been bedridden for 2 weeks due to acute illness. During a skin assessment, a purple, intact area of skin is noted over the sacrum. The area is firm and painful to palpitation. Which intervention is MOST appropriate at this stage?
An 85-year-old patient has been bedridden for 2 weeks due to acute illness. During a skin assessment, a purple, intact area of skin is noted over the sacrum. The area is firm and painful to palpitation. Which intervention is MOST appropriate at this stage?
A patient with a venous leg ulcer reports increased pain and elevated lower extremity edema despite consistent compression therapy. Duplex ultrasonography reveals deep vein reflux and perforator vein incompetence. What adjuvant intervention should the clinician IMMEDIATELY integrate into the patient's care plan to address the source of venous hypertension?
A patient with a venous leg ulcer reports increased pain and elevated lower extremity edema despite consistent compression therapy. Duplex ultrasonography reveals deep vein reflux and perforator vein incompetence. What adjuvant intervention should the clinician IMMEDIATELY integrate into the patient's care plan to address the source of venous hypertension?
When transferring a BMAT Level 1 patient, defined as being fully dependent, what is the SAFEST and most appropriate method to utilize?
When transferring a BMAT Level 1 patient, defined as being fully dependent, what is the SAFEST and most appropriate method to utilize?
What degree of patient's hip tilt is recommended when side-lying to offload the greater trochanter?
What degree of patient's hip tilt is recommended when side-lying to offload the greater trochanter?
After prolonged immobilization, an ICU patient is initiating a progressive mobility program. Following initial tolerance of sitting at the edge of the bed during a physical therapy session, what is the MOST appropriate next step in their progressive mobility plan?
After prolonged immobilization, an ICU patient is initiating a progressive mobility program. Following initial tolerance of sitting at the edge of the bed during a physical therapy session, what is the MOST appropriate next step in their progressive mobility plan?
According to the Frailty Index, a score of 3 or higher indicates frailty. When evaluating an elderly patient, which combination of factors would MOST likely contribute to this score?
According to the Frailty Index, a score of 3 or higher indicates frailty. When evaluating an elderly patient, which combination of factors would MOST likely contribute to this score?
During chart review to determine wound etiology, what laboratory value provides the MOST INSIGHT into a patient's long term glycemic control over the past 2-3 months?
During chart review to determine wound etiology, what laboratory value provides the MOST INSIGHT into a patient's long term glycemic control over the past 2-3 months?
When considering mobility interventions for an ICU patient, what is the MOST CRITICAL consideration concerning the patient's integumentary system?
When considering mobility interventions for an ICU patient, what is the MOST CRITICAL consideration concerning the patient's integumentary system?
When using a Roho cushion for pressure redistribution, what parameter is MOST IMPORTANT to ensure the cushion is properly inflated?
When using a Roho cushion for pressure redistribution, what parameter is MOST IMPORTANT to ensure the cushion is properly inflated?
A 65-year old male is referred to physical therapy post-CABG x3 and has been on bed rest for 5 days with an order to begin ambulation. During chart review, you note the patient's albumin is 2.8 g/dL. What is the MOST IMMEDIATE concern?
A 65-year old male is referred to physical therapy post-CABG x3 and has been on bed rest for 5 days with an order to begin ambulation. During chart review, you note the patient's albumin is 2.8 g/dL. What is the MOST IMMEDIATE concern?
A patient is evaluated for a chronic lower extremity wound and presents with shiny, hairless skin, and diminished pedal pulses. What is the MOST LIKELY underlying condition and the MOST appropriate intervention?
A patient is evaluated for a chronic lower extremity wound and presents with shiny, hairless skin, and diminished pedal pulses. What is the MOST LIKELY underlying condition and the MOST appropriate intervention?
What is the primary biomechanical advantage of using a draw sheet during patient repositioning?
What is the primary biomechanical advantage of using a draw sheet during patient repositioning?
Which equipment is the MOST appropriate for lateral transfers of immobile patients and is described as an air-assisted lateral transfer device that reduces the force needed to move patients?
Which equipment is the MOST appropriate for lateral transfers of immobile patients and is described as an air-assisted lateral transfer device that reduces the force needed to move patients?
What is the MOST CRITICAL initial action when dealing with suspected overinflation in a ROHO cushion?
What is the MOST CRITICAL initial action when dealing with suspected overinflation in a ROHO cushion?
A patient has a burn on their axilla. What is the best position to prevent contractures?
A patient has a burn on their axilla. What is the best position to prevent contractures?
Following a burn injury, a patient is at high risk for developing hypertrophic scarring across the anterior neck. What is the MOST appropriate orthotic intervention to prevent contracture?
Following a burn injury, a patient is at high risk for developing hypertrophic scarring across the anterior neck. What is the MOST appropriate orthotic intervention to prevent contracture?
Which of the following factors is MOST responsible for the reduced adherence between the epidermis and dermis in aging skin?
Which of the following factors is MOST responsible for the reduced adherence between the epidermis and dermis in aging skin?
In the intricate landscape of geriatric wound care, a clinician observes an unstageable pressure ulcer obscured by significant eschar on the ischial tuberosity of a frail, malnourished patient. What is the MOST IMPERATIVE initial intervention, considering the complexities of tissue assessment and the potential for undermining?
In the intricate landscape of geriatric wound care, a clinician observes an unstageable pressure ulcer obscured by significant eschar on the ischial tuberosity of a frail, malnourished patient. What is the MOST IMPERATIVE initial intervention, considering the complexities of tissue assessment and the potential for undermining?
An 87-year-old patient with a history of poorly controlled diabetes mellitus and peripheral neuropathy presents with a painless foot ulcer exhibiting a 'cookie-cutter' appearance, surrounded by thick callus. Vascular assessment reveals palpable pedal pulses. Which biomechanical intervention is MOST crucial in the long-term management of this ulcer to prevent recurrence, addressing the underlying pathomechanics?
An 87-year-old patient with a history of poorly controlled diabetes mellitus and peripheral neuropathy presents with a painless foot ulcer exhibiting a 'cookie-cutter' appearance, surrounded by thick callus. Vascular assessment reveals palpable pedal pulses. Which biomechanical intervention is MOST crucial in the long-term management of this ulcer to prevent recurrence, addressing the underlying pathomechanics?
A researcher is designing a study to investigate the impact of advanced glycation end products (AGEs) on the healing rate of full-thickness excisional wounds in a murine model of aged skin. Which methodological approach would MOST precisely isolate the effect of AGEs from confounding variables inherent in the aging process, allowing for definitive conclusions regarding their role?
A researcher is designing a study to investigate the impact of advanced glycation end products (AGEs) on the healing rate of full-thickness excisional wounds in a murine model of aged skin. Which methodological approach would MOST precisely isolate the effect of AGEs from confounding variables inherent in the aging process, allowing for definitive conclusions regarding their role?
A 70-year-old male, is admitted post-stroke exhibiting left-sided hemiplegia, aphasia, and impaired skin integrity over the sacrum (Braden Scale score: 11). During interdisciplinary rounds, a debate arises regarding the optimal pressure redistribution strategy, given the patient's high risk for further skin breakdown and limited ability to communicate discomfort. Which intervention should be prioritized, considering the competing factors of cost-effectiveness, practicality in the acute care setting, and robust evidence supporting its efficacy?
A 70-year-old male, is admitted post-stroke exhibiting left-sided hemiplegia, aphasia, and impaired skin integrity over the sacrum (Braden Scale score: 11). During interdisciplinary rounds, a debate arises regarding the optimal pressure redistribution strategy, given the patient's high risk for further skin breakdown and limited ability to communicate discomfort. Which intervention should be prioritized, considering the competing factors of cost-effectiveness, practicality in the acute care setting, and robust evidence supporting its efficacy?
A clinician is developing a comprehensive fall prevention program for an elderly patient with a history of recurrent falls, impaired balance, and documented sensory neuropathy. While addressing environmental hazards and medication management, which targeted therapeutic intervention MOST directly addresses the underlying neuromuscular deficits contributing to the patient's instability, thereby minimizing the risk of future falls?
A clinician is developing a comprehensive fall prevention program for an elderly patient with a history of recurrent falls, impaired balance, and documented sensory neuropathy. While addressing environmental hazards and medication management, which targeted therapeutic intervention MOST directly addresses the underlying neuromuscular deficits contributing to the patient's instability, thereby minimizing the risk of future falls?
Flashcards
Function of Integumentary System?
Function of Integumentary System?
Maintains homeostasis, provides an immune barrier, and synthesizes vitamin D.
Purpose of Epidermis?
Purpose of Epidermis?
Protects skin from infection and drying, maintains fluid balance, gives feedback, and has specialized cells.
Purpose of Dermis?
Purpose of Dermis?
Responsible for skin durability and flexibility, prevents heat loss, regulates body temperature and is responsible for outer epidermis.
Hypodermis/Subcutaneous
Hypodermis/Subcutaneous
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Keratinocytes function
Keratinocytes function
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Langerhans cells function?
Langerhans cells function?
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Melanocytes function?
Melanocytes function?
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Merkel cells function
Merkel cells function
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Fibroblasts function
Fibroblasts function
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Mast cells function
Mast cells function
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Macrophages function
Macrophages function
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Reduced blood flow effect
Reduced blood flow effect
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Capillary fragility
Capillary fragility
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Reduced collagen/elastin effect
Reduced collagen/elastin effect
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How do wounds occur?
How do wounds occur?
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Superficial partial thickness?
Superficial partial thickness?
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Deep partial thickness?
Deep partial thickness?
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Full thickness?
Full thickness?
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Skin tear
Skin tear
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Skin tear classification Type 1
Skin tear classification Type 1
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Skin tear classification Type 2
Skin tear classification Type 2
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Skin tear classification Type 3
Skin tear classification Type 3
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Arterial compromise
Arterial compromise
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Venous compromise
Venous compromise
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Arterial Insufficiency presentations
Arterial Insufficiency presentations
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Arterial Insufficiency Wound
Arterial Insufficiency Wound
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Venous Insufficiency presentations
Venous Insufficiency presentations
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Venous Insufficiency Wound
Venous Insufficiency Wound
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Neuropathic Wounds
Neuropathic Wounds
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Arterial Ulcer Characteristics
Arterial Ulcer Characteristics
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Venous Ulcer Characteristics
Venous Ulcer Characteristics
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Neuropathic Ulcer Characteristics
Neuropathic Ulcer Characteristics
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What can cause pressure ulcers?
What can cause pressure ulcers?
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Screening tools to determine if a patient will form a wound?
Screening tools to determine if a patient will form a wound?
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Categories of risk of development of a wound?
Categories of risk of development of a wound?
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Unstageable Ulcer
Unstageable Ulcer
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Stage 4 Pressure Ulcer
Stage 4 Pressure Ulcer
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Older Adult Wound Healing?
Older Adult Wound Healing?
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What is frailty?
What is frailty?
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Clinical criteria for frailty
Clinical criteria for frailty
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Medications to Note
Medications to Note
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ABI
ABI
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Pressure Ulcer Prevention?
Pressure Ulcer Prevention?
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Pressure Ulcer Documentation Includes
Pressure Ulcer Documentation Includes
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Interventions for burns?
Interventions for burns?
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NIOSH Standards
NIOSH Standards
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Interventions for pressure ulcer?
Interventions for pressure ulcer?
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Study Notes
Review of Integumentary System
- Function of the integumentary system it to maintain homeostasis; including fluid balance and thermoregulation.
- It provides an immune barrier.
- Synthesizes vitamin D.
Skin - Epidermis
- The epidermis to protects skin from infection and drying.
- It maintains fluid balance and avoids excessive evaporative water loss.
- Gives feedback for pain, touch, pressure, and sensation.
- It is avascular and has specialized cells.
Skin - Dermis
- The dermis is responsible for skin durability and flexibility.
- It prevents excessive loss of body heat.
- Regulates body temperature.
- It is responsible for the outer epidermis; if the dermis is completely destroyed, wound cannot heal.
- It is a layer that is vascular and innervated.
- Has hair follicles, sweat glands, blood vessels, and nerves held in place by collagen.
Skin - Hypodermis/Subcutaneous
- The hypodermis is the deepest layer of the skin.
- It consists of subcutaneous tissue.
Skin Layers and Cells
- The epidermis consists of keratinocytes, Langerhans cells, melanocytes, and Merkel cells.
- Keratinocytes migrate through the epidermis and convert to dead keratinized cells that form the physical epidermal barrier.
- Langerhans cells cause immune activation.
- Melanocytes are responsible for contributing to skin color and sun protection.
- Merkel cells are for light touch sensation.
- Dermis contains fibroblasts, mast cells, and macrophages.
- Fibroblasts synthesize collagen and elastin; they are the primary cell involved in granulation formation for soft tissue repair/scar.
- Mast cells are responsible for the release of histamine and heparin.
- Macrophages are phagocytic and chemotactic.
Consideration of Aging Skin
- With age, blood flow to the area decreases.
- There is a decrease in sensory structure, and elasticity.
- Thermoregulation decreases.
- There is an increased fragility of capillaries.
- Overall reduced blood flow leads to slower healing, decreased thermoregulation, and reduced dermal thickness.
- Increased fragility of capillaries leads to an increased risk of ecchymosis and appearance of senile purpura.
- Reduced collagen can lead to reduced dermal thickness, decreased skin elasticity, flattening of epidermal/dermal projections, wrinkles, and sagging of skin.
- Reduced subcutaneous fat and redistribution causes decreased thermoregulation, wrinkles, and sagging skin.
- Flattening of epidermal/dermal projections leads to decreased adherence between epidermis and dermis.
- Decreased activity and number of sebaceous glands can cause Xerosis, and an itch-scratch cycle can lead to skin breakdown/infection/scarring, reduced skin barrier function, increased skin irritation and dermatosis, and increased pH of the skin.
- Decreased sensory structures causes decreased fine motor ability, increased risk of injury and slight delay detecting harmful stimuli.
- Decreased number of hair follicles leads to slower partial thickness re-epithelialization.
- Black/brown hyperpigmented spots are typically benign; located on sun-exposed skin due to years of exposure.
- Reduced production of melanin results in decreased protection from the sun and increased DNA damage.
- Depleted hair follicle melanocytes causes the appearance of grey hair.
- Ridged and thickened fingernails causes brittle, weak, hypertrophic nails.
- Decreased upward migration of epithelial cells and reduced desquamation leads to slowed wound healing.
Trauma
- Wounds occur when forces; blunt and shear, exceed the tolerance of the tissue.
- Trauma can happen as an unplanned injury related to thermal injuries like burns or frostbite, animal bites, MVAs, falls, and skin tears.
Depth of Burn Injury
- Newer terminology classifies burns by depth of injury.
- Superficial partial thickness affects the epidermis and upper part.
- Deep partial thickness affects the epidermis and large upper portion.
- Full thickness destroys all skin.
- Fourth degree or subdermal involves complete destruction of epidermis and subcutaneous tissue with muscle damage.
Burn Classification
- Superficial burns are red and dry, blanch with pressure, and are painful, and heal within 3-6 days.
- Superficial partial thickness burns are moist with blisters. They are red and weeping, blanch with pressure, painful to temperature and air, and heal in 7-21 days.
- Deep partial thickness burns have blisters that are easily unroofed, they are wet or waxy dry, and have variable color, and do not blanch with pressure. Requires >21 days to heal, and may need surgical treatment.
- Full thickness burns are waxy white to leathery gray to charred and black, dry and inelastic, and exhibit no blanching with pressure. Insensate with only deep pressure, rare, unless surgically treated.
- Deeper injuries extend to fascia and muscle; only deep pressure felt, and never treated unless surgically.
Skin tears
- Skin tears: a traumatic wound caused by mechanical forces, including removal of adhesives (ISTAP).
- Severity and prevalence vary.
Skin Tear Classification
- Type 1: No skin loss; flap can cover the whole wound bed when repositioned.
- Type 2: Partial flap loss; flap does not cover the wound bed, even when repositioned.
- Type 3: Total flap loss; wound bed is exposed.
Vascular Issues
- Arterial compromise causes poor blood flow in the arteries; can lead to ischemia, stroke, and embolism, and can be seen anywhere.
- Venous compromise are blood flow problems in the veins, mostly seen in lower extremities.
Arterial Insufficiency
- It is associated Peripheral Arterial Disease (PAD).
- Its risk factors are increased age, diabetes, hypertension, obesity, smoking, and high cholesterol.
- Its presentation is that the skin is shiny, cool, and hairless and wounds are in distal lower extremity.
Arterial Insufficiency Wound
- Location: distal portions of the lower extremity.
- Little drainage.
- Necrotic tissue may be present.
- Pulses may be weak or absent.
- Altered capillary refill.
- Painful.
Venous Insufficiency
- Venous insufficiency is associated with lower extremity edema, chronic venous insufficiency, and varicose veins.
- Risk factors include high BMI, obesity, hypertension, and DVT.
- Presentation are edema and drainage and wounds in distal lower extremity
Venous Insufficiency Wound
- Location: distal portions of the lower extremity.
- Has shallow irregular borders.
- Drainage present.
- Normal capillary refill.
- Painless.
- Hemosiderin staining.
Neuropathic Conditions:
- Neuropathic wounds caused by diabetes.
- Wounds in pressure areas of the foot.
- Loss of protective sensation on monofilament is the cause.
Neuropathic Wounds: Peripheral neuropathy causes:
- Decreased sebaceous gland release and dry skin, causing increased callus due to fissures and increased areas of skin breakdown; related to autonomic ramification.
- Inability to perceive harmful levels of pressure, can cause an increased likelihood of skin breakdown and is related to sensory ramification.
- Muscle atrophy causes deformity, e.g., claw toe/hammer toe, and an gradient of pressure; related to motor ramification. Change in foot posture (Motor dysfunction) increased pressure motor gradients of the skin leading to increased skin breakdown risks
Vascular Ulcers:
- History for a venous ulcer are varicose Veins, DVT, trauma, surgery to leg, or multiple pregnancies.
- History for a arterial ulcer are smoking, intermittent claudication.
- History for a neuropathic ulcer is numbness, paresthesias, burning, or loss of sensation in the foot.
- Location for venous ulcer between Malleolus and the lower calf
- Location for arterial ulcer are distally and over bony prominences.
- Location for neuropathic ulcer are sites of pressure.
Pressure Ulcers
- Pressure ulcers are due to anything touching the patient that could cause skin breakdown.
- Often hospital acquired.
- Screening for pressure ulcers includes the Braden scale.
Braden Scale
- 6 categories of risk: mobility, activity level, sensory perception, nutritional status, exposure to moisture, friction, and shear.
- Each category is rated on a scale of 1-4, except friction and shear 1 to 3.
- Possible total would be 23 points; higher scores are lower risk.
- Very high risk: 9 or less.
- High risk: 10-12.
- Moderate risk: 13-14.
- Mild risk: 15-18.
- No risk: 19-23.
Pressure Ulcer Staging
- Staging was developed by National Pressure Injury Advisory Panel (NPIAP).
- Based on anatomic depth of soft tissue.
- Requires complete visualization for accurate staging.
- Wounds covered by eschar and slough are unstageable.
- Stage 1: intact skin with redness and changes in sensation, temperature, or firmness; if incontinent, use EPC. If continent, apply a foam dressing
- Stage 2: partial thickness loss of skin with exposed dermis; wound visible; if incontinent, use EPC. If continent, apply a foam dressing
- Stage 3: full thickness loss of skin with depth; fatty tissue is visible (yellow/white). Minimal depth: intra-site gel to wound bed and cover with dry dressing. Moderate depth: intra-site gel to wound bed and lightly fill with NS damp gauze and cover with dry dressing
- Stage 4: full thickness loss of skin and tissue with exposed fascia, muscle, tendon, ligament, cartilage, or bone. Intra-site gel to wound bed and lightly fill with NS damp gauze and cover with dry dressing.
- Unstageable: full thickness skin and tissue loss in which the extent of damage cannot be confirmed due to eschar or slough. If removed, a stage 3 or 4 will be revealed.
- Heel eschar should be painted with betadine and open to air.
- Coccyx eschar requires a thin layer of EPC covered with exu-dry.
- Slough in wound bed use intra-site gel lightly filled with damp gauze and cover with exu-dry.
- If there is drainage/odor, consult surgery.
- Deep tissue is intact or non-intact skin with localized area of persistent un-blanchable deep red, maroon or purple discoloration, or a blood-filled blister.
- Coccyx treatment is to apply touchless care zinc oxide.
- Heel treatment is to apply skin prep, leave open to air then apply fleeces or boots on patient.
Older Adult Wound Healing
- Increased time of inflammation can affect wound healing.
- Tensile strength of a wound is less in older adults compared to younger adults.
- Healed wounds will not exceed 70-80% of strength of original tissue.
- Older adults with newly healed wounds only have 15% of original skin strength.
- Rate of re-epithelization decreases with age.
- Scar maturation takes longer.
Frailty
- A clinical syndrome of weight loss, fatigue, and weakness.
Operational Definition of Frailty
- Frailty is a clinical syndrome with 3 or more of the following (Fried 2001):
- Low physical activity; ~270 kcal/wk women, ~383 kcal/men
- Slow walking; <.65 m/sec for 15 feet associated with falls
- Weak grip
- Loss of 10 lbs in the past year- unintentional
- Self-report of exhaustion (3 or more days/wk)
- A person is considered pre-frail if they meet 1-2 of the above criteria.
Clinical Pictures of Frailty Include:
- History of falls.
- Poor nutrition.
- Sedentary style and don't get outside.
- Muscle weakness is very common.
- Depression/confusion.
- Decreased gait speed.
- Decreased strength.
- Decreased balance.
- Decreased endurance.
ICU Survivor Issues-Frailty
- Frailty traditionally associated with elderly people.
- Frailty is a hot topic in acute care literature.
- It is being studied in ICU and post-ICU patients.
- Study of 1040 patients admitted to multiple ICUs.
- Found frailty present in 1 out of 3 patients who were 18 or older.
- Half of all patients with frailty were younger than 65.
Physiological Effects of Bedrest:
- Slowed: muscle mass, strength, endurance, and nerve conduction.
- Slowed: Resting & Max SV, CO, VO2, Orthostatic tolerance, and bone mineralization
- Increased: Thrombosis/embolism risk, Venous stasis, and urinary stasis, and calculus formation.
- Increased: Insulin resistance, HR (rest + activity), and sensitivity to thermal stimuli.
Sarcopenia
- Sarcopenia: loss of skeletal muscle mass can be attributed to old age.
- Caused by a decrease hormones and protein deficiency.
- Loss of alpha motor input of muscle and physical inactivity
Implications of M-S Changes:
- Important to encourage strength training.
- Encourage weight baring exercise.
- Encourage movement towards end range.
- Avoid jarring exercises.
- Encourage warm ups.
- Important to educate patients on modifiable risk factors for bone loss early.
Patient Client Management includes reviewing the chart for:
- Patient history - comorbidities, obesity, previous wounds, diabetes, vascular insufficiency.
- Lab values for HbA1C and Albumin.
- Poor nutrition.
- ABI and angiograms.
Lab Values
- Hemoglobin A1C tests for long-term index of average blood glucose.
- Increased blood sugar levels are associated with an increased risk of ulceration and impaired wound healing.
- Albumin levels falling rapidly indicate protein deficiency or malnutrition and levels less than 3.2 mg/dL associated with longer length of stay.
- There is a positive correlation between low serum albumin and pressure injury severity.
- Mortality risk increases as prealbumin levels drop and indicators of the effect of nutritional intervention.
- CBC can be used to help determine anemia, infection and oxygen carrying capacity.
- SED can determine infection and iflammatory process.
Ankle Brachial Index
- Ankle Brachial Index (ABI) is the ratio of systolic blood pressure at the ankle to the brachial systolic pressure.
- Ankle SBP is taken on the posterior tibial artery or dorsalis pedis and blood pressure can be obtained using Doppler.
- ABI sensitivity is 95% and specificity is 99%
0.9 < 1.3 -- normal <.8 ------ problematic < .4 ------ see wound healing issues
- It does not work well with calcified tibial arteries in patients with diabetes.
- A falsely high value >1.3 can be a problem.
Medications that affect wound healing:
- Polypharmacy
- Corticosteroids
- Anticoagulants
- Immunosuppressants
- NSAIDs
- Chemotherapy drugs
Evaluation/Screening
- Wound history, pain, social situation, systems review, cognition, neuro exam, balance/sensation, musculoskeletal, ROM, MMT, and skin integrity.
- Edema, Vancouver scar, pulses, ABI, pressure injury screen, cardiopulmonary, diet, smoking history and mobility assessment.
FRAIL Screen
-
F: Fatigue – “Are you fatigued?”
-
R: Resistance – “Cannot walk up 1 flight of stairs?”
-
A: Aerobic – “Cannot walk 1 block?”
-
I: Illnesses – “Do you have more than 5 illnesses?”
-
L: Loss of weight– Have you lost more than 5% of your weight in the past 6 months
-
Scores are 3 or greater is frailty, 1 or 2 is prefrail
Functional Markers
- The TUG to determine functional mobility.
- The following values are needed to determine fun from failure.
| Marker | FUN | FIT | Frail | Failure |
|---|---|---|---|---|
| TUG (sec) | <8 | 9-20 | >20 (sec) | N/A |
| Gait Speed (m/sec) | >1.5 | .9 to 1.5 | .5 to .8 | <.5 |
Evaluation/Screening
- Incorporation into Evaluation Screening
- Inspection of weight bearing and contact surface.
- position evaluation
- Device and bed surface evaluation.
Positioning
- Position the patient in alignment to reduce skin breakdown, and pain.
Common Posture and their Corrective Splints/Orthotics
- Neck
- Neck flexion : Neutral slight extension
- Neck Extention : Neutral slight flexion
- Axilla
- Adduction, IR Abduction,ER
- Elbow
- Flexion, pronation : extension supination
- Wrist
- Wrist flexion : Neutral ext
- Wrist Extension : Neutral flexion
Common Positioning and Deformity
- Area Burned
- Location Position
- Flexion,Addiction,IR : Neutral IR/ER
- Knee
- Flexion : ext
- Ankle
- Plantar Flexion : Neutral df/pf
Mobility Considerations
- Mobility Considerations
- Prevention of shear
- 30 deg angle of bed
- Repositioning Equipment
- protection of integration
- Promotion of mobility
- Patient handling Aids.
Interventions
- Important to remember OSHA guidelines.
- New revised OSHA ( National institute for occupational safety lifting equation says the safe weight lift 35LBS insurance my cover tools that work to make the process safter.
APTA
- “Transforming society by optimizing movement to improve the human experience.
Intervention
- Incorporation into evalution screening
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