Integ. Unit 1

Question 1

How is the skin organized into?

Answer 1

• Epidermis: This is an avascular superficial layer
• Dermis: This is a vascular under layer

Question 2

What are the functions of the skin?

Answer 2

• Protection
• Sensation
• Maintenance of fluid
• Immunity
• Thermoregulation

Question 3

The Epidermis is comprised of 5 layers that contain important cellular functions, what are the layers from superfical to deep?

Answer 3

1. Stratum Corneum
2. Stratum Lucidum
3. Stratum Granulosum
4. Stratum Spinosum
5. Straum Basale

Question 4

What are the Primary Cells of the Epidermis?

Answer 4

• Keratinocytes
• Melanocytes
• Langerhans Cells
• Merkel Cells

Question 5

What is the Dermis?

Answer 5

• This is a vascular layer near the basement membrane
• This binds the epidermis to subcutaneuous tissue (hypodermis)
• And contains encapsulated nerves

Question 6

What is the Cellular Composition of the Dermis?

Answer 6

• Fibroblast
• Meissner’s Corpuscles
• Pacinian Corpuscles
• Hair Follicles

Question 7

What 3 things characterizes wound by level of involvement?

Answer 7

• Severity
• Level of tissue involvement
• Color of the wound

Question 8

Would Classification: Color

What does a classification of a Red wound mean?

Answer 8

2° Granulation tissue
- Normal healing

Question 9

Would Classification: Color

What does a classification of a Yellow wound mean?

Answer 9

Fibrin left from the healing process
- Yellow slough on wound base
- Medium for bacterial growth

Question 10

Would Classification: Color

What does a classification of a Black wound mean?

Answer 10

Eschar, indicates necrosis
- Cannot accurately assess wound covered in eschar

Question 11

If a patient has a Red wound, what is indicated?

Answer 11

Clean, Healing; granulation

Question 12

Skin Loss

What is Erosion? What are the Clinical Signs?

AKA superficial wound

Answer 12

Erosion is epidermal loss only

Clinical Signs:
- Erythema and minimal to no bleeding

Such as superficial burns (1st degree burns)

Question 13

Skin Loss

What are Partial Thinkness Wounds? What are the Clinical Signs?

Answer 13

Partial Thickness Wounds is loss of both epidermis and dermis

Clinical Signs:
- Bleeding

Such as 2nd degree burns or skin tears

Question 14

What are Full Thickness Wounds? What are the Clinical Signs?

Answer 14

Full Thickness Wounds is loss of the epidermis, dermis and hypodermis

Clinical Signs:
- Possible exposure of bone/tendon/ligament/muscle

Such as Surgical Incisions, wound requiring debridement of necrotic tissue

Question 15

With the skin, what is the healing response?

Answer 15

• Cell signaling
• Macrophage activity
• Follows 4 general phases:
  Hemostasis -> Inflammation -> Proliferation -> Remodeling

Question 16

With Healing Responses, what are the characteristics of
Phase 1: Hemostasis?

Answer 16

• Takes less than 1 hour

Primary Characteristics:
-Platelet Aggregation
-Cellular Action and clot formation (scab)
-Brief arteriole vasoconstriction
-Influx of neutrophils

Clinical Signs:
- Inflammation
- Edema

Question 17

With Healing Response, what are the characteristics of Phase 2: Inflammation?

Answer 17

• Takes between 1hr to 4 days
• The goal is to increase cirulation to the site of injury

Primary Characteristics:
-Vasodilation
-Leukocyte and macrophage formation
-Angiogenesis: formation of new blood vessels
-Autolytic debridment

Clinical Signs:
- Increased body temperature
- Rubor, Tumor, Dolor, Calor

Question 18

With Healing Response, what are the characteristics of Phase 3: Proliferation?

Answer 18

• Takes between 4-12 days

Primary Characteristics:
-Angiogenesis of small vessels
-Formation of new extracellular matrix and epidermal cells
-Proliferation of fibroblast
-Proteogycan/collagen synthesis
-Granulation tissue formation

Clinical Signs:
- “Beefy red” granulation tissue (with full-thickness)
- Re-epithelialization occurs after granulation tissue

This is the "Beefy Red" Granulation Tissue

Question 19

With Healing Response, what are the characteristics of Phase 4: Maturation/Remodeling?

Answer 19

Primary Characteristics:
-Wound contraction
-Fibroblast to myofibroblast conversation
-Melanocyte aggregation
-Increased tensile strength
–recidivism
-Collagen replacement

Clinical Signs:
- Blanching

Question 20

What are the 3 classifications of wound response?

Answer 20

• Healing by primary intention
• Healing by delayed primary intention (aka tertiary)
• Healing by secondary intention

Question 21

What is Healing by Primary Intention?

Answer 21

• Minimal tissue loss and good approximation
  –Eventually secured with staples, surgical, or sutures
• No scab formation noted secondary to minimal cell death
• Resolves in approximately 2 weeks

Ex. Surgical incisions clear or bacteria/pathogens

Question 22

What is Delayed Primary Intention (aka Tertiary Intention)?

Answer 22

• Suspected debris or pathogens in the wound
• Resulting granuloma
• Marked inflammation response
• Usually closed surgically once deemed free of pathogens/debris

Question 23

What is Secondary Intention?

Answer 23

• Usual wound healing process for non-surgical wounds
• Myofibroblast aid in wound closure

Clinical Note:
- Wound seen in the clinic will be of either delayed primary intention or secondary intention

Question 24

What is the Extracellular Matix comprised of?

Answer 24

• Collagen (structural protein)
  –Helps formulate new tissue
• Elastine (Structural protein)
  –Stretch properties
• Proteoglycans (GAGs

Question 25

How do Chronic wounds usually occur from? How long does it take to heal? ## Footnote What is the most common type of chronic wound?

Answer 25

Usually occur due to: - Foreign debris in the wounds - Pathogenic occupants - Disease Chronic wounds may take months or years to close ## Footnote Venous Insufficiency ulcers

Question 26

What are some Impeding Factors to healing?

Answer 26

- Infection - Medications - Comorbidities - Cancer/Radiation - Autoimmune Disorders - Stress - Modifiable behaviours/lack of sleep

Question 27

What are 2 types of infections that affect wound healing?

Answer 27

- Bacterial Infection - Fungal Infection

Question 28

What types of medications can affect wound healing?

Answer 28

**Steroids** - It delays all phases of healing - Vitamin A may be effective **NSAIDS** - Possible decrease of platelet aggregation - Decreased tensile strength of tissue

Question 29

What are different Co-morbidities that can affect wound healing?

Answer 29

**Diabetes** - Healing can be delayed due to the effects of increased glucose levels on leuokocyte function **Arterial Insufficiency** - This results in a decreased ability for waste products to be removed and for nutrients to be delivered to the site of injury **Chronic Edema** - which may cause venous indufficiency, which will limit the blood that can circulate through more proximal vasculature and fluid remains in the distal extremities **Cardiac Diseases** - Any heart disease automatically predisposes the person toward poor wound healing

Question 30

How can Cancer/Radiation affect wound healing?

Answer 30

- Radiation destroys the good cells capable of wound healing as well as the malignant cancer cells. Also we would see a decrease in tissue tensile strength - Chemotherapy may cause a decrease in blood flow and sensation to the extremities, this may lead to further tissue degradation. Also affects the nutritional system

Question 31

What psychosocial behaviors affect wound healing and how?

Answer 31

**Stress** - Results in high levels of cortisol which delay the inflammatory phase - Hormones allow for vasoconstriction **Smoking** - This causes vasoconstriction, which then decreases wound healing process **Alcohol** - Excessive alcohol consumption can lead to increased insulin resistance and high blood glucose levels inhibiting healing in all phases - Greater than 4 drinks/day or 14 drinks/week

Question 32

# Identifying Factors: Abnormal Lab Values If a person has Increased or Decreased WBCs, how may this affect wound healing? ## Footnote What is considered Normal?

Answer 32

- If a persons WBCs are increased, this may indicate infection or trauma - If a persons WBCs are decreased, this may indicate a decreased immune response to bacteria **Both of these cause a delay in wound healing** ## Footnote Normal is 4.5-11x 10^3/mm^3

Question 33

# Identifying Factors: Abnormal Lab Values If a person has increased or decreased hemoglobin, how may this affect wound healing? ## Footnote What is considered Normal?

Answer 33

- If a persons hemoglobin count is increased, this may indicate that wound may fail to progress - If a persons hemoglobin cout is decreased, this may indicate the wound may fail to progress/may have pale appearance ## Footnote Normal is 12-18 g/dL

Question 33

# Identifying Factors: Abnormal Lab Values If a person has increased or decreased Hematocrit, how may this affect wound healing? ## Footnote What is considered Normal?

Answer 33

- If a persons hematocrit is increased, this may be a sign of throbi/emboli - If a persons hematocrit is decreased, this may be a sign that the wound will fail to progress/may appear pale ## Footnote Normal between 36-50%

Question 34

# Identifying Factors: Abnormal Lab Values If a person has increased or decreased Prothrombin time IRN (PT-IRN), how may this affect wound healing? ## Footnote What is considered Normal?

Answer 34

- If a persons Prothrombin time IRN (PT-INR) is increased, this may be a sign that the wound will bleed easily - If a persons Prothrombin Time IRN (PT-IRN) is decreased, this may be a sign of increased clotting ## Footnote Normal is 2.50 seconds

Question 35

# Identifying Factors: Abnormal Lab Values If a person has increased HbA1C%, how may this affect wound healing? ## Footnote What is considered Normal?

Answer 35

*Blood sugar* - If the persons HbA1C% is increased this may indicate delayed wound healing ## Footnote Normal is ≤5.7%

Question 36

# Identifying Factors: Abnormal Lab Values If a person has increased Average Glucose, how may this affect wound healing? ## Footnote What is considered Normal?

Answer 36

- If the persons Glucose is increased this may indicate delayed wound healing ## Footnote Normal is < 100 mg/dL