Term
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Definition
| microbes on the surface of something; non-replicating & NO host response |
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Term
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Definition
| microbes replicating on the surface; NO host response |
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Term
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Definition
| critical point at which the pt. has in increase in the # of microbes that becomes a bioburden and adversely affects the individual |
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Term
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Definition
Replicating microbes invade viable tissue
As a general rule, 10^5/g |
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Term
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Definition
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Term
| 4 potential problems associated with wound infection |
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Definition
1. Maintained inflammatory response (prominent necrotic tissue - stimulating breakdown & creation of more necrotic tissue)
2. Increased metabolic demand
3. Tissue necrosis
4. Risk of abcess |
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Term
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Definition
Bioburden (# of microbes involved)
Virulence (either a lot of microbes or how amt. of lethal toxin produced)
Host Resistance (person probably doesn't have a normal, healthy immune system) |
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Term
| 4 big players in infection control |
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Definition
Hand-washing
Universal Precautions
Standard Precautions
Following directions |
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Term
| Two techniques that assist with Infection control |
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Definition
Clean - no sterile field or gloves (WP, US, stim electrodes)
Sterile - sterile gloves, sterile field, sterile instruments - set up and maintain sterile field & keep dry |
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Term
| Indications for using sterile technique over clean |
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Definition
1. Burns
2. Immunocompromised patients
3. Large wounds
4. Packing (deep/tunneling wounds) |
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Term
| What is the infected wound presentation in terms of an inflammatory response? |
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Definition
Out of proportion for what is expected with inflammation
Ex. Rubor - extensive, poorly defined peri-wound with streating & extensive elevation
Calor - High temp. than expected
Dolar - more pain than expected
Tumor - excessive swelling
Functio laesa - systemic weakness - "don't feel good" vs. having function affected only at the wound site as with inflammation |
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Term
| Inflammation presentation out of proportion for what's expected - Infection? |
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Definition
| No, but would make person suspicious - not sufficient for dx |
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Term
| Drainage with infected wounds |
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Definition
more purulent, viscous, more (amount)
could be blue-green (pseudomonas aeruginosa)
increased foul odors |
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Term
| Foul odors - cause for concern? |
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Definition
| Only after cleaning wound or if smell changes - taking off bandage and smelling a foul odor isn't a cause for concern |
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Term
| 4 types of wound cultures |
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Definition
Tissue biopsy - gold standard
Fluid aspiration - typically with abcess - can be risky
Swabbing - only gets surface bacteria - recommend alginate tip - should really only do with an order
Microbiology - gram staining (+/-) - helps choose best antibiotic |
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Term
| Osteomyelitis & Diagnosis |
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Definition
Bone or bone marrow infection (MRSA - staph aureus usually culprit)
Diagnosis - usually tricky - hidden
poor healing
bone biopsy/aspiration
imaging
If you can see or touch bone, assume osteomyelitis until proven otherwise |
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Term
| Fungal infection diagnosis |
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Definition
Gomori-Wheatley
Acridine Orange |
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Term
| Why fungal infections get worse if treated with antibiotics or anti-inflammatories |
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Definition
| Knocking out the body's natural defenses to fight the fungus - will proliferate unchecked |
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Term
| Interventions for infected wounds |
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Definition
Anti-microbials (antibiotics, antiseptics, anti-fungals) - topical or systemic
Debridement
Modalities |
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Term
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Definition
better to use more specific (aerobic vs. anaerobic; gram +; gram -) - using broad spectrum antibiotics can lead to drug resistance (Ex. MRSA & Vancomycin resistant Enterococcus - lucky they aren't more resistant)
Can use topical or systemic (silver being used as a broad-spectrum topical) |
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Term
| Systemic vs. Topical Antibiotics |
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Definition
| Topical may be better - pt. could have issues with systemic circulation or drug metabolism |
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Term
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Definition
broadly anti-microbial - kills healthy, healing tissue along with immune cells
Bleach, Acetic Acid, Hydrogen Peroxide, Betadine (Povidone iodine)
May be useful in short term applications for multi-microbial wounds |
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Term
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Definition
Removal of necrotic tissue
Necrotic tissue is breeding ground for microbes, lowers wound oxygenation, occupies host cells trying to clean it up, and blocks granulation & epitheliazation
Can do with many different instruments (Pulse lavage, Water pick, sharp) |
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Term
| Bacteriocidal vs. Bacteriostatic |
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Definition
Bacteriocidal - kills bacteria
Bacteriostatic - prevents replication of bacteria |
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Term
| Modalities used for tx of wound infection |
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Definition
UV light
E-stim (cathodal pulsed, Hi-Volt, DC) - does not help with osteomyelitis - promoting closing of the wound over infectious bone; not sure if it helps with biofilms |
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Term
| Planktonic Model of microbes |
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Definition
We thought most bacteria lived this way - not true
Hydrophilic, free floating
min. glycocalyx
susceptible to antibiotics & antibacterial agents |
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Term
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Definition
Most bacteria live this way
Strong glycocalyx coating to keep out body's defenses
occur at a given pop. density (quorum) - interacting communities of microorganisms
Enhance drug resistance
May turn body's own defenses against - fibrin coating
Work synergistically to optimize replication (ex. aerobes can help anaerobes survive in oxygenated environment)
Resistant to neutrophils - create virulence factors to kill or weaken neutrophils
Can survive and outlive treatment & restart infection once antibiotics are stopped |
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Term
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Definition
Mainly strep - colonizes in fissures & contact points in teeth
uses sucrose to make glycocalyx & stick to teeth
Byproducts trapped within biofilm and assist with adhesion to tooth - has acids that destroy tooth enamel & dentin |
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Term
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Definition
Slow penetration
Stress Response
Altered Microenvironment - if testing surface microbes, wouldn't detect diff. strain here
Persisters - never seem to die - always seem to be able to re-colonize |
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Term
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Definition
Debridement - frequent & aggressive
Selective biocides - silver, Iodosorb, Hydrofera Blue (topical)
Antibiofilm agents - Lactoferrin, Xylitol, Farnasol, Plant products, fatty acid gel
Antibiotics (Adjunct, strong & long) |
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Term
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Definition
| Used as a antibiolfim agent in tx. of biofilms - keeps microbes from using iron - binds to iron - could potentially cause anemia - no iron left for Hemoglobin to bind |
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Term
| Indications for PT's to treat wounds |
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Definition
| chronic, healing by secondary intention, taking longer than 2-6 weeks to heal |
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Term
| Criteria for a CHRONIC wound |
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Definition
wound does not close in a timely manner or maintain healed state in 2-6 weeks
wound has arrest or prolonged phases of healing (stuck or absent inflammation, one example) |
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Term
| 3 things that can happen to the physiological healing response of wounds |
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Definition
Normal timeline interuppted
Normal timeline prolonged
Normal timeline constantly restarted |
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Term
| Things that go wrong in normal physiological wound healing that cause chronic wounds |
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Definition
(P H Never Eats Sushi In Tokyo)
Infection
Perfusion
Senesence
Hydration
Nutrition
Excessive/Prolonged Inflammation
Trauma |
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Term
| Perfusion as a factor in chronic wounds |
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Definition
Necessary for full inflammatory process
brings in wbc's to remove necrotic tissue
Need oxygen to support healing processes
carries away metabolic byproducts & tissue breakdown components |
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Term
| Hydration as a factor in chronic wounds |
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Definition
moist wounds are best - too dry or too wet - BAD
diffusion distance increases with wet wounds - bad
wet, macerated skin is weak - blisters can peel off
dry wounds are prone to more inflammation, cracking, crusting, & impaired epithelialization (epithelial tissue doesn't want to move across dry tissue - granulation tissue not growing) |
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Term
| Nutrition as a factor in chronic wounds |
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Definition
often overlooked
need to look at GI disturbances d/t meds
necessary to promote wound healing substrates
Loss of subcutaneous tissues (fat -soluble vitamins (A,D,E,K) - important co-factors associated with wound healing) |
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Term
| Inflammation as a factor in chronic wounds |
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Definition
from repetitive (ex. wet-dry dressing) or unrelieved trauma (ex. not getting off a pressure ulcer) or systemic conditions
inflammation promotes tissue damage & delayed revascularization |
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Term
| Trauma as a factor in chronic wounds |
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Definition
mechanical (could be d/t immobility, loss of protective sensation, or treatment related)
chemical (inflammatory) - can treat with antiseptics |
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Term
| Wound Senescence as a factor in chronic wounds |
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Definition
associated primarily w/ aging, but can be in any chronic wound
reduced growth factors in exudate compared to acute wounds (causes reduced proliferation of healthy cells - could be biofilm - virulence factors produce chemicals that turn off defense cells and impair growth factors)
Chicken & Egg (do you have chronic wound b/c of reduced growth factors or does the chronic wound cause reduced growth factors) |
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Term
| Wound Senesence as a Factor in Chronic wounds with inflammatory process |
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Definition
All cell types exhibit reduced/impaired rate of replication, PRO synthesis, & motility
PRO synthesis - fragments fibronectin - dry wound, looks like a breakdown product - simulates inflammatory response - macrophages want to eat up cellular debris - stuck in inflammation - can't proliferate like you want - inflammation works against wound |
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Term
| Reimbursement of E-stim for chronic wounds |
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Definition
| only reimbursed if used as a last or second resort after other failed treatments were tried first - can be used in conjunction w/ other treatments for INFECTIOUS wounds & be reimbursed |
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Term
| Hallmarks of Chronic wounds through the 3 physiological phases |
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Definition
Inflammation - out of proportion or too long a time; prominent necrotic tissue; usually drainage (variable)
Proliferation - either pale granulation tissue or hyper or hypo graulated (most probs with hypogranulation); tissue integrity not re-established
Epithelialization - rolled wound edges (epibole), edges may be disconnected from wound bed (undermining), hypertrophic scars |
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Term
| Arterial Insufficiency Ulcer characteristics |
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Definition
5-10% fo LE ulcers
Impaired tissue oxygenation (can be ass. w/ LDL & blood lipids, diabetes, smoking, neurovascular disorders (Raynaud's, Buerger's)
Spontaneous ulceration rare - usually a minor insult that causes (metabolic supply can't meet demand)
Look good, but are much harder to treat & could require surgery
initial insufficiency asymptomatic usually
Chief symptoms - intermittend claudication (cramping during activity d/t decreased O2 to tissues - pt. rests & goes away) - only 1/3 of pts with more than 50% occlusion present with IC |
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Term
| AI ulcers & 7 Factors with chronic wounds |
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Definition
Perfusion - decreased
Hydration - wound dried out - not a lot of drainage
Nutrition - may be ok or bad systemically, but impaired at the wound site
Excessive/prolonged inflammation - decreased inflammation - not a lot of weeping and tissue breakdown - not as much cellular debris
Senescence - appear stuck in proliferation - still in granulation - not able to get new vascularization to support
Infection - at increased risk - don't show inflammation signs - need to look for other markers like increase in glucose, fever, wbc count (immune system still making, just can't get to where they need to go); anaerobic bacteria will thrive
Trauma - could occur as a result of a minor insult - bump against w/c |
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Term
| Infectious AI Ulcers - Presentation, Progression through healing, & Tx |
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Definition
Presentation - asymptomatic or IC
Progression - stuck in granulation - can't get new vascularization for healthy granulation tissue
Often requires surgical treatment (vascular bypass graft if they have enough healthy vessels to harvest) or walking program to improve collateral circulation
*if patients have pain with rest & worse with elevation - walking program won't help, likely to need sx
Could try heat, but convection most likely impaired - have to be careful (could help increase blood flow)
w/ walking program, have to catch early - pt. walks until they get symptoms, then rest & progressively increase as tol. - didn't increase resting blood flow, but increased whole limb blood flow |
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Term
| Venous Insufficiency Ulcers |
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Definition
Most common (70-90%)
cycle of venous HTN, venous backflow, & venous distention
Venous stasis - vascular trauma (inflammation), impaired flow - wbc trapping, and have unwanted activation of the clotting pathways
spontaneous ulcerations more likely d/t excessive edema |
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Term
| VI Ulcers & 7 factors affecting chronic wounds |
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Definition
Perfusion - increased edema d/t 1 - increased diff. distance & 2 - edema occludes vessels d/t buildup of pressure
Hydration - wet, seeping
Nutrition - May be impaired systemically or not, but def impaired at wound site
Excessive/Prolonged Inflammation - bigger factor
Senescence - usually have inflammatory damage to deal with
Infection - already having a large inflammatory response, so need to watch for infection
Trauma - can also open d/t minor trauma as with AI |
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Term
| How venous stasis promotes edema |
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Definition
| Veins not reabsorbing fluid in interstitium - increased fluid in area already, & inflammation creates even more, which can lead up to buildup of necrotic tissue & even more edema |
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Term
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Definition
better than AI, but more prone to recurrence with improper management
Often have combined AI & VI pathology & need to treat correctly - both have very diff. indications for treatment |
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Term
| Pressure Ulcers - Presentation |
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Definition
Localized tissue necrosis resulting from mechanical compression (perpendicular force into plane of tissue)
AKA decubitus ulcers, decubitii - not good terms, imply pt. is lying down and pt's can get pressure ulcers in other positions
Problem with perfusion - ischemic injury - inflammatory response will vary with vascular status
Usual pressure points - sacrum, isch tubs, greater troch, heels, coccyx (can develop on ANY part of the body - nostrils from NC, DHT, scalp from immob. on vent)
Can get in joint spaces of contracted limbs & where body parts kiss - butt, knees |
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Term
| Pressure Ulcers - main emphasis, & pop. at risk |
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Definition
Emphasis - PREVENTION - health care costs over $70,000/ulcer
Pop. at risk - SCI, Elderly (post hip fx) in ECF or SNF |
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Term
| Pressure issues with pressure ulcers |
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Definition
Areas of the body affected with different positions - supine (70 mm Hg) on butt, sitting on butt (300 mm Hg)
Capillary closing pressure - 13-32 mm Hg
Soft tissue helps distribute forces |
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Term
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Definition
| inside out - have to relieve the pressure or it won't heal |
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Term
| Pressure Ulcer Risk factors |
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Definition
Intrinsic - age, smoking, nutrition, co-morbidities (mobility, sensation, previous ulcer)
Extrinsic - moisture (maceration of skin, incontinence), shear (force parallel to soft tissue can compromise or injury vasculature - tear drop wound), friction can weaken epidermis |
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Term
| Inappropriate treatment for Pressure Ulcers |
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Definition
Donut - just creates a larger pocket of ischemia around wound and makes wound larger
Antiseptics - don't want to kill viable tissue & prevent healing |
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Term
| Pressure ulcers and how they affect 7 factors of chronic wounds |
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Definition
Perfusion - decreased d/t ischemia from pressure
Hydration - problem locally - can be either wet or dry
Nutrition - big problem usually d/t the population at risk for pressure ulcers
Excessive/Prolonged Inflammation - keep re-insulting injury & can't heal
Senescence - wound stuck in inflammation d/t constant re-insult
Infection - risk increases in elderly population in nursing homes d/t incontinence
Trauma - keep putting pressure on wound |
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Term
| Neuropathic Ulcers - at risk patients |
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Definition
Diabetic ulcers - DM patients - 80% result in amputation, 50% have contralateral limb ulcer within 1.5 years of amputation
3 year survival post amputation is 35-50% |
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Term
| Neuropathic ulcers - 3 Neuropathies & how they contribute to chronic wounds |
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Definition
Sensory - pt. can't feel & doesn't check for skin breakdown
Motor - pt. immobile and can't perform pressure reliefs - progress distal to proximal - have weakened intrinsic foot muscles (dropped arch & have changes to shape of foot causing diabetic foot ulcers
Autonomic - altered moisture maintenance - pt. could have dry skin w/ callous & then have excessive perspiration with movement & have skin come off in chunks (skin weakened w/ moisture) |
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Term
| Factors in place in DM that place patients at risk for Neuropathic ulcers |
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Definition
Vascular problems leading to neuropathy
Poor nutrition/Metabolism
Problems with Keratinization, Proliferation, & Re-epithelialization (d/t insulin deficiency)
Changes in denervated skin (Decreased Type 1 collagen & increased Type III); reduced andrenergic receptors, & loss of GAGs to urinary excretion |
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Term
| Problem with the name "Neuropathic ulcers" as its own class |
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Definition
| causes aren't really neuropathies - just another form of AI, VI, or pressure ulcer d/t Diabetes |
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Term
| Assessment, tx., & prognosis of Neuropathic Ulcers |
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Definition
Assessment - need to do vascular assessment as with other ulcers - check distal pulses - sensory neuropathy among greatest risk factors (repetitive trauma) - do monofilament testing
Prevention is best treatment strategy - pt./fam. ed (tell pt's to wash & dry carefully & use moisturizing lotion as a preventative barrier), general diabetes education, foot & ulcer ed., footwear & foot care
Multiple pathologies make for a poor prognosis |
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Term
| Impaired perfusion mechanisms in Arterial insufficiency, VI, & Pressure ulcers |
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Definition
Art. - decreased circulation - can't pump blood with neutrophils, O2, and other requirements for proper healing
VI - venous return impaired - blood pools in LE & have fluid swelling & decreased re-uptake of waste products of inflammation
Pressure - ischemic at site of injury - can't get inflammatory process moving until pressure off of affected area |
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Term
| Underlying cause of impairment in AI, VI, & pressure ulcers |
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Definition
AI - poor circulation
VI - occluding vessels & buildup of edema
Pressure - ischemia caused by external pressure closing off capillaries |
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Term
| Interventions for AI, VI, & pressure ulcers |
|
Definition
Arterial insufficiency - walking to increase collateral circulation or sx
Venous - compression therapy (if indicated by physician), walking may help (unna boot) or could increase edema; paced impregnated bandage - dries up and gives a little something extra for the wound to push against; manage moisture w/ absorbing bandages; elevation
Pressure - relieve & redistribute pressures - if wound is clean - do tot. contact casting - casts perfectly & follows contour of foot & have distribution of forces (not all on one elevated spot) |
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Term
| Different mechanisms for wounds (including most common) |
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Definition
Most common - mechanical (blunt force/sharp trauma)
Chemical, Electrical, Thermal (both hot & cold) |
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Term
|
Definition
can be misleading - often certain wounds have their own staging systems (ex. pressure ulcer)
Superficial - Epidermis only
Superficial & Deep Partial thickness - Epidermis & Papillary Dermis or Epidermis through reticular dermis
Full thickness - deeper than dermis - includes subcutaneous tissues |
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Term
| 3 Phases of wound healing |
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Definition
Inflammation, Proliferation, Remodeling/Maturation
Phagocytosis & Debridement, CT synthesis, Epithelialization & Collagen formation |
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Term
| Kind of immunity most associated with wounds & why |
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Definition
Innate - more general response, responds quickly
Acquired - responds to a specific antigen - kicks in if wound is infected or if antigens are present |
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Term
| Some characteristics of the inflammatory phase of wound healing |
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Definition
Rapid, coordinated response to injury/infection/disease
Restores/Maintains homeostasis
Non-specific
Multiple systems
Normal, necessary step in promoting recovery
Usually successful in isolating & destroying injurious factors & debris - consequences of this often have to be addressed |
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Term
| Vascular response to inflammation - general |
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Definition
cardinal signs of inflammation
vasoconstriction - stop bleeding (have vessel changes); platelet & coagulation cascade
Vasoconstriction - prepare for recovery - vessel changes, fluid dynamics |
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Term
| Cellular response to inflammation - general |
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Definition
| clear debris, fight invaders, movement of wbc's to injury (margination & emigration), chemotaxis (cytokines, cellular debris, complement (innate)) |
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Term
| Vascular response to inflammation - Vasoconstriction |
|
Definition
Initial, temporary hypoxia to stop bleeding (anaerobic & lactic acid processes)
Have platelet activation to create a plug, then clotting cascade - makes fibrin as its end product - clot - creates a pathway for later collagen deposition & monocytes & fibroblasts
Activated platelets release cytokines & growth factors (TGF beta, PDGF) |
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Term
| Vascular response to inflammation - Vasodilation |
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Definition
increased capillary permeability (increase in histamine & prostaglandins)
Increase in size of lumen & decrease in blood flow |
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Term
| Cellular response to inflammation |
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Definition
decreased BF & increased lumen from vasodilation
PMN's pushed to the sides of vessel walls (called margination) - enter through vessel walls by emigration (diapedesis)
Circulating monocytes become macrophages in interstitium & clean debris by phagocytosis
MMP's break down collagenous tissue
Produce cytokines to further modulate inflammation & promote subsequent proliferation & antibacterial effects
O2 more necessary for for anti-bacterial actions
Chemotaxis - makes pro-inflammatory cytokines, cellular debris (runs on hypoxia/lactate processes)
Galvanotaxis - current of injury - skin surface (-) vs. inside - allows current flow with injury - impeded in dry & chronic wounds |
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Term
| Proliferative phase - when it occurs & what it does (general) |
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Definition
overlaps with inflammatory phase (could start within 48 hours)
Rapid cell division & growth |
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Term
| Proliferative phase - 4 main processes |
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Definition
Angiogenesis
Granulation
Contraction
Re-epithelialization |
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Term
|
Definition
formation of new blood vessels
directed by VEGF & chemical mediators
have initial hypoxia (stimulates growth of new vessels)
Have inflammatory cytokines, growth factors, etc.
Stimulates capillary buds, which leads to formation of new capillary beds (buds seen as red dots in wound bed - stipling)
New capillary beds provide nutrients & cells (cho & pro - fibroblasts for collagen secretion; removes wastes; relieves edema) |
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Term
|
Definition
MMP's degrade debris formed during inflammation & granulation tissue (highly vascular) takes its place
ECM produced by firbroblasts - matrix allows fibroblasts to advance across wound bed
Fibroblasts guided by chemotaxis & low O2 - as more vascularization occurs, stimulus for fibroblast proliferation decreases
Temoporarily fills wound defect - scar tissue or replacement tissue takes its place
High in fibronectin & Hyaluronic acid (glycoproteins -(very hydrated tissues)) |
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Term
| Wound contraction - production of myofibroblasts & properties of myofibroblasts |
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Definition
fibroblasts stimulated by TGF beta - induces production of CTGF - causes fibroblasts to diff. into myofibroblasts
have contractile apparatus similar to smooth muscle (have actin filaments)
produce large amounts of collagen & other ECM proteins
normally transient
autocrine - secretes something on itself to activate itself |
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Term
| Contraction - what happens, what affects it |
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Definition
myofibroblasts pull wound margins together
amount of contraction based on shape, depth, & size (larger, circular, deeper wounds all hard to close)
limited by dermal compliance - no proliferation; thin dermis remodeled to normal thickness |
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Term
|
Definition
autocrine - secreting something on itself to activate itself
paracrine - secreting something to activate cells nearby |
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Term
|
Definition
sometimes classified as a separate phase
Occurs at margins of wound, across healthy granulation tissue
Have resurfacing by keratinocytes
Chemotactic factors in wound influence epithelial migration & proliferation
Highly metabolic process (requires O2)
fibrin clot is digested & healthy tissue formed from bottom up |
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Term
| Epithelialization around dermal appendages |
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Definition
| epithelialization doesn't just occur at wound margins - can radiate outward from spared glands & hair follicles |
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Term
| Epithelialization - problems that occur if granulation not complete |
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Definition
| If no healthy granulation tissue to advance across, epithelial tissue could meet on itself & create a rolled edge - could also have abcess |
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Term
| Epithelialization & Diabetes |
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Definition
| decrease in insulin could cause reduces proliferation & differentiation of keratinocytes |
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Term
| Goals of proliferation phase |
|
Definition
Mostly associated with closing of wounds or amounts of tissue types in wound
Ex. Wound will decrease in size to ___mm by ___ days/weeks
Ex. Wound will contain at least ___ amt. of granulation tissue by ____days/weeks. |
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Term
| Restored barrier function |
|
Definition
| epithelialization - end of proliferation phase |
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Term
|
Definition
remodeling/strengthening of CT
Synthesis & Lysis (breaking down clot & filling in with viable CT) - lysis can be anaerobic but synthesis is aerobic
High collagen synthesis - Type III to Type I
Alignment & reorientation - usually based on Tension theory - maturation guided by stresses placed on tissue - rather than induction theory - tissue becomes the tissue around it
Phase may take up to 2 years |
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Term
|
Definition
| excessive collagen synthesis, but remains in confines of wound margin - hypertrophic scarring of burns likely d/t long proliferative phase |
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Term
|
Definition
Excessive collagen synthesis
progresses outside initial wound margins
Ethnic pigmentation & genetic predisposition
could prevent both ROM (ex. flex & ext.) if bad enough |
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Term
|
Definition
shortening of scar tissue resulting in deformity or loss of ROM
associated with hypertrophic scars & keloids |
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Term
|
Definition
separation of wound margins d/t insufficient collagen production or tensile strength
NOT d/t wound infection
Pt's with predisposition for decreased collagen tensile strength at risk - DM, steroid users, malnourished |
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|
Term
| Four problems with scarring |
|
Definition
Keloids, Hypertrophic scarring,
Contractures, Dehiscence |
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|
Term
| Mechanism for problems with scarring |
|
Definition
| Tissue highly vascularized during proliferation (granulation tissue) if decrease in oxygenation doesn't occur, tissue grows out of control and have increased scar tissue growth, like keloids or hypertrophic scarring |
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Term
| Wounds healing by primary intention |
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Definition
| Physical approximation of wound edges (surgically usually) - could close dehiscence |
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Term
| Delayed primary intention |
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Definition
| leaving wounds open for a time, intending to close by primary intention later |
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Term
| Wound closure by secondary intention |
|
Definition
includes skin grafts
edges can't be approximated (d/t size, infection, tissue quality, etc.)
more granulation is needed to fill defect
more wound contraction necessary
dehiscence can occur here too |
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Term
| Way to accelerate normal, healthy healing of wounds - potential problems with it |
|
Definition
autologous, platelet rich plasma
Platelets have PDGF, EGF, VEGF, & TGF - beta
Potential problems - if person already has underlying pathology, using own cells probably won't help |
|
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Term
|
Definition
Rashes - temporary
Primary
Secondary
Suspicious
Infected |
|
|
Term
|
Definition
Dermatitis
Urticaria (hives) |
|
|
Term
|
Definition
Flat - Macule, Patch
Elevated - Plaque, Papule, Nodule, Tumor, Wheal
Fluid-filled, Elevated - Vesicle, Bulla, Pustule, Cyst |
|
|
Term
|
Definition
often from staph aureus
"furuncles" - raised area full of necrotic & purulent tissue - often happen around hair follicles
carbuncles - multiple, interconnected furuncles
cellulitis |
|
|
Term
|
Definition
Scab
Abrasion
Fissure
Erosion
Scale
Ulcer
Scars |
|
|
Term
| Skin - Types, general info |
|
Definition
Mucocutaneous - jxn of mucous membrane, hairy skin, lips, & tongue
Mucous membrane - lines inside of body orifices
Glabrous
Hairy
15-20% of body mass
requires 1/3 resting CO
CT - cells, fibers, ground substance |
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Term
| Skin - 4 General functions |
|
Definition
Serves as protection from environment (UV, microbes, mechanical stresses)
Immune function (low pH - could be increased by handwashing or diabetes/CHF) & Langerhans (dendritic cells) - lose SALT (skin associated lymphoid tissue - lose effectiveness of mounting immune response)
Maintains homeostasis - hydration status, thermoregulation, helps maintain vitamin d levels
Provides sensory input through mechanical & thermosensitive receptors |
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Term
|
Definition
.06-.6mm
Appendages derived from here
avascular - depends on diffusion from dermis
complete turnover on a roughly monthly basis
Provides physical barrier & plays a role in Vit. D synthesis
Mostly keratinocytes (5 layers - S. Corneum - sup.)
Also have Melanocytes (melanin granules face direction of sun to protect nu.) - pigmentation; Merkel cells (mechanoreceptors) - anchored to keratinocytes - receive info from anchors around them, & APC's (dendritic cells) - prominent in Stratum Spinosum - important for our system to recognize and mount an immune response against a foreign antigen
Also, beta carotene |
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Term
|
Definition
2-4 mm
highly vascular
have dermal pappillae - mirrored by epidermis -allow SOME resistance to mechanical stress - blisters build up here
appendages anchored here (hair, nails, glands)
2 layers - highly vascular - Papillary Dermis (anchored to epidermis via basement membrane - LICT) & Reticular Dermis (DICT)
Have fibroblasts, macrophages, & mast cells |
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Term
|
Definition
Sebaceous glands (oil)
Sweat glands - Eccrine (Merocrine) & Apocrine - Eccrine - all over skin, esp. glabrous - cholinergic innervation; Apocrine - in selective places, like axilla, scalp - andrenergic - function debatable - know it responds to adrenaline but don't know if its innervated or responds to circulating adrenaline |
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Term
| Subcutaneous layer of skin |
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Definition
hypodermis - very variable in thickness - both within & across individuals, dependent on adiposity
Energy stores & fat soluble vitamins (lose subcutaneous layer and can be deficient in A,D, E, K
has fascia - irregular or regular dense connective tissue
Larger blood vessels & lymphatics
have more fat deposition over body prominences |
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Term
|
Definition
skin is labile (readily undergoes change or breakdown)
40% of all cancers are skin cancers
Malignant melanomas - only 4% of cancers, but 79% of deaths
Basal & squamous cell - much more common, but very high cure rate, esp. if found early |
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Term
|
Definition
Increased vulnerability to injury & epidermal & dermal atrophy (CVC ESTIM)
Reduced cell turnover
Reduced vasculature
Reduced Collagen quality
Reduced Elastin
Diminished Sensation
Impaired Thermoregulation
Reduced Immune function
Altered Moisture Maitenance |
|
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Term
| EGF - Function & Effect on Wound healing |
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Definition
Growth factor (epidermal growth factor)
stimulates angioblasts, fibroblasts, & keratinocyte proliferation - chemotactic factor for fibroblasts & keratinocytes |
|
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Term
| Platelet-Derived Growth factor (PDGF) - Function & effect on wound healing |
|
Definition
Growth factor
- chemotactic factor for macrophages & PMN's
- Stimulates proliferation of fibroblasts, keratinocytes, & angioblasts
- Stimulates matrix production
- Stimulates angiogenesis
- Is the first growth factor approved for use in US & Canada |
|
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Term
| Transforming Growth Factor beta (TGF- beta) - Function & Effect on Wound-Healing |
|
Definition
Growth factor
- Reverses steroid-impaired wound healing
- Regulates matrix formation & collagen synthesis
- Stimulates antiogenesis
- Stimulates Epithelialization
- Involved in scar formation
- Stimulates cell growth |
|
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Term
| Tumor Necrosis Factor - alpha - Function & Effect on Wound Healing |
|
Definition
Cytokine
- Stimulates fibroblasts
- Activates neutrophils
- Stimulates inflamatory mediators
- Stimulates Angiogenesis |
|
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Term
| Vascular endothelial growth factor (VEGF) - Function and Effect on Wound Healing |
|
Definition
Growth factor
- stimulates angiogenesis |
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Term
|
Definition
| Superficial - Epidermis only (ie sunburn - NO blistering) |
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Term
|
Definition
Superficial partial thickness - involves epidermis and papillary dermis - moist, weeping, blistered - quick capillary refill
Deep partial thickness - Involves Epidermis and Reticular dermis - mottle white & red, likely no blisters, sluggish capillary refill, but still blanches |
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Term
|
Definition
| Full thickness burn - involves all of dermis and hypodermis - no blanching - appears white, gray, or black (leathery & dry) |
|
|
Term
| 3 Different zones of burn wound depth |
|
Definition
Zone of coagulation
Zone of Stasis
Zone of Hyperemia |
|
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Term
|
Definition
| only in Full-thickness burns - area of greatest destruction, irreversible cellular death, appears dry & leathery, less painful, does NOT blanch to pressure, and varies in color (white, tan, gray, black, brown) |
|
|
Term
|
Definition
Most critical zone
Temporarily lacks normal blood supply but is NOT avascular - with proper treatment, can revascularize area & damage minimized - w/out proper tx, pt. can lose blood flow and viable tisue, extending Zone of Coagulation (a potentially viable area converted to a necrotic area)
Appears moist, painful, blanches to pressure, red, blisters |
|
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Term
|
Definition
area furthest from injury - viable tissue, vascularity maintained - no cell death
Appears dry, painful, blanches to pressure - pink-red in color |
|
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Term
| Determination of extent of tissue destruction |
|
Definition
Temp. of heat source
Duration of contact
Thickness of involved skin |
|
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Term
|
Definition
Lund & Browder
Child - Head & neck = 18%, arms 18%, trunk = 36%, legs = 28%
Adult - Head & Neck = 9%, Arms = 18%, Trunk = 36%, Genitals = 1%, Legs = 36% |
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Term
| Most immediate life-threatening response to burn injury & cause |
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Definition
burn shock
typically d/t hypovolemia (loss of circulating fluid) - results from shifts & losses of fluid from the circulation which often leads to dramatic edema |
|
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Term
| Severity of burn shock influences |
|
Definition
extent & depth of injury
age of patient
general physical condition of the patient |
|
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Term
|
Definition
| 8-12 hours post injury with smaller burns & 12-24 hours post-injury with major thermal injuries |
|
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Term
| Infection tissues in burns |
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Definition
Non-invasive - when microorganisms are limited to the burn eschar
Invasive - microorganisms invade underlying viable tissue
Septicemia - presence of microorganisms in the circulating blood |
|
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Term
| Intact skin vs. Burned skin structure |
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Definition
Intact skin - collagen, elastin, & ground substance
Burned skin - elastin not readily replaced & has no significant role in wound repair |
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Term
| Collagen as a component of skin |
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Definition
Most abundant fibrous component of skin & scar tissue
In the normal dermis, collagen bundles are wavy with ample interstitial space - in burn scar, collagen bundles have mixed orientation, whorl-like pattern, & are tightly woven
Collagen provides strength to tissue - more collagen, more strength |
|
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Term
| Elastin as a component of skin |
|
Definition
allows skin to possess some elasticity
helps maintain skin in a state of constant tension
no distinctive pattern of orientation
forms a network between the collagen fibers (elastin responsible for returning stretched collagen to its resting state)
adds little tensile strength to skin |
|
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Term
| Ground substance as a component of skin |
|
Definition
gel-like component found in between, surrounding, & t/o fibrous network of collagen & elastin
composed of interstitial fluid & a group of high molecular weight substances called glycosaminoglycans (GAGS)
GAGS - large macromolecules composed primarily of carbohydrates with varying amounts of protein; one function of GAGS = helps provide normal suppleness and turgor of the skin - the viscosity of the ground substance is related to the content of the GAGs which may play a role in the inelasticity of burn contracture |
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Term
| Amount of ground substance in Dense & Loose CT |
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Definition
Dense - small
Loose - lots |
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Term
|
Definition
| dermal appendages - hair, nails, glands |
|
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Term
| Factors that trigger keratinocytes at wound edge & adnexal epithelial cells to migrate on wound surface |
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Definition
1. Loss of cell-cell contact leads to signals for keratinocytes to migrate
2. Growth factors released from wound that target keratinocyte growth & migration
3. When keratinocytes come into contact with certain proteins, they are simulated to migrate |
|
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Term
|
Definition
|
|
Term
| Wounds with ____ heal fastest |
|
Definition
| highest conc. of skin adnexa |
|
|
Term
| 3 main changes in healed burn wounds |
|
Definition
sensation
skin
scar contracture |
|
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Term
| Sensory changes in a healed burn wound |
|
Definition
decreased sensation (depending on depth of injury)
increased sensitivity to ambient temp. (cold worse)
itching, pain
scar management program if skin is hypersensitive |
|
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Term
| Scar contracture in the healed burn wound |
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Definition
Effect on ROM - secondary to pain, patient assumes a position of comfort - could lead to new collagen fibers in the wound fusing together in a shortened length - immobilization & fusing collagen across joint - limited range/contracture
Effect on appearance - always have a scar |
|
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Term
| Skin changes in the healed burn wound |
|
Definition
skin very fragile - minimize irritation (no soaking in tub)
Pigmentation - could be hyper or hypo
Color intensity can change daily & overall color changes gradually over several months
Lasting changes relate to amount of melanin in surviving skin - directly related to depth of injury
Lubrication - since sebaceous glands destroyed, need to augment skin lubrication. If not, can get cracking & skin breakdown |
|
|
Term
| 5 reasons for a pt. to transfer to a burn unit |
|
Definition
Burns of hands, face, perineum, feet, & major joints
Inhalation injury
Chemical burns
Electrical burns
Pt's with pre-existing medical disorders that could Third degree burns
Second degree burns >10% TBSA |
|
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Term
| Burns that will spontaneously heal |
|
Definition
| Up through Superficial partial thickness - Deep Partial thickness unsure if it will heal on its own or not - wait for demarcation |
|
|
Term
| _______ results from circumferential burns |
|
Definition
|
|
Term
| S&S of vascular impairment in burns |
|
Definition
| pallor, pain, paresthesia, & no pulse |
|
|
Term
| Techniques used in burn pt's to relieve swelling |
|
Definition
Escharotomy - incision into burn tissue lat. & med. - across involved joints
Fasciotomy - used as a second resort after escharotomy if pulses don't return - deeper incision down through fascia |
|
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Term
| When pulses don't return after fasciotomy |
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Definition
| tissue necrosis occurs - amputation likely |
|
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Term
|
Definition
removal of non-viable tissue using a dermatome or scalpel
reduces risk of infection & sepsis
must be excised until there is good capillary bleeding for a graft to adhere |
|
|
Term
| Options for wounds that do not heal spontaneously |
|
Definition
Temporary wound coverage - Allograft/Homograft
Autograft (Sheet/Mesh)
Muscle Flaps
Integra
Cultured Skin Substitutes |
|
|
Term
|
Definition
allograft/homograft - cadaver skin
body usually rejects in 2-3 weeks
provides a protective barrier while donor sites heal for future harvesting |
|
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Term
| Only acceptable permanent coverage for a burn wound |
|
Definition
|
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Term
|
Definition
Split thickness autografts - only epidermis & portion of dermis - have mesh & sheet
Full-thickness - epidermis & all of dermis |
|
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Term
|
Definition
A strip of donor site is taken and transferred without alteration to burn area
- more durable than mesh grafts
- more cosmetic
- contracts less
- disadvantages: blood or bacteria can collect under graft, causing graft loss |
|
|
Term
|
Definition
Donor skin fed through Tanner mesher which can expand skin from 1 1/2 to 9 times original skin size
Advantages - less donor sites are needed & allows passage of exudate through the interstices
Disadvantages: meshed appearance is permanent, less durable than sheet grafts, & contracts more |
|
|
Term
|
Definition
excising the skin down to but not including subcutaneous tissues
more durable - contracts less than STSG's
good for palmar burns, groin, abs |
|
|
Term
| Donor sites in burn patients |
|
Definition
STSG sites similar to superficial partial thickness burns - epithelialization required for healing
Epidermal appendages left intact - generally heal w/in 14 days
FTSG can be closed by primary intention - typical sites include groin or abdomen |
|
|
Term
|
Definition
Effective in covering areas that are relatively avascular (over bone & tendon)
seen most commonly in electrical burn patient exit wounds
involves transferring skin, subcutaneous skin, & muscle
flap must have blood supply connected from the muscle to the new wound bed |
|
|
Term
|
Definition
Bi-layer - inner dermal replacement (permanent) made up of collagen matrix with outer silicone temporary layer
often used at trunk
Vessels grow up into collagen matrix & pt. must be immobile for 4-5 days, then have same precautions as autograft
takes about 2-3 weeks for vascularization to take place
Outer silicone layer peeled off and epidermal autograft is placed |
|
|
Term
|
Definition
Epicel - commercially available for large TBSA burns - Marketed under Humanitarian Device Exemption permission - no multicenter study of efficacy
- does not contain dermis which gives skin its strength
- does not adhere well, blisters, contracts a LOT, thin
Research being done to transplant donor keratinocytes for use with chronic wounds (not necessarily burns) |
|
|
Term
|
Definition
| Steven Boyce at Cincinnati Shriners working on cultured skin with keratinized epidermis & dermal substitute - currently in process of FDA approval |
|
|
Term
| Components of Initial Assessment in burn patients |
|
Definition
Burn date
TBSA
Cause
Reason for admission (wound care, excision & grafting, rehab, social reasons)
Involved Areas
Associated Injuries
Significant history (congenital probs, ADD, cardiac, respiratory problems, TBI, diabetes, pregnancy)
SKin condition
Edema
ROM
Strength
ADL/functional skills (feeding, grooming, dressing, toileting)
Developmental status
Social hx
Hand dominance
Hearing aid
Glasses
Mobility/Ambulation
Behavioral emotional status
Major stressors
Pre-admit rehab program
Rehab prognosis
Short & long term goals |
|
|
Term
| Mechanism for hypertrophic scarring |
|
Definition
increase in collagen synthesis & increase in production of collagenase (but to a much lesser extent) - imbalance between collagen synthesis & deradation that leads to excessive scarring
Also, collagen fibers in HS are in a whorl-like pattern instead of parallel like normal collagen fiber arrangement |
|
|
Term
| Mechanism for hypertrophic scarring |
|
Definition
increase in collagen synthesis & increase in production of collagenase (but to a much lesser extent) - imbalance between collagen synthesis & deradation that leads to excessive scarring
Also, collagen fibers in HS are in a whorl-like pattern instead of parallel like normal collagen fiber arrangement |
|
|
Term
| Factors affecting scar formation |
|
Definition
Race - darker pigmented races more likely
Age - >30 scar more - more skin redundancy & decreased collagen metabolism
Location - sternum, upper back, deltoid area, buttocks, & dorsal foot scar more
Depth - Deeper burns involving reticular dermis scar more d/t formation of granulation tissue & prolonged healing time |
|
|
Term
| Compression therapy & Pressure w/ research |
|
Definition
No study confirms the mechanism by which pressure alters structure of scars
Compression used at Shriners based on clinical findings |
|
|
Term
| Hypothetical effects of compression on burn scars |
|
Definition
decreased blood flow
flattening of the scar
increased pliability
decreased rate of collagen synthesis
realignment of collagen bundles in a parallel pattern |
|
|
Term
| Guidelines to use compression therapy (with burns) |
|
Definition
<10 days to heal = no compression needed
10-14 days to heal = monitor for compression needs
14-21 days to heal = prophylactic compression is highly suggested
>21 days to heal - compression therapy mandatory |
|
|
Term
| Proper application of ace wraps in burn patients |
|
Definition
wrapping distal to proximal & overlapping one half of bandage width on each successive turn - no shear force
don't initially use d/t swelling |
|
|
Term
| Proper application of Coban |
|
Definition
applied WITHOUT a shearing force
good for use on hands & feet
can restrict movement somewhat |
|
|
Term
| Tubular Support Bandage (TSB) |
|
Definition
used when the surface can tolerate a minimal amount of shearing force
usually used as a temporary compression after ace wraps and before custom garments
can be used as definitive pressure on small children or small burns
TSB come in different sizes but have consistent diameter - can be tapered using a surger or an insert can be used to fill the concavity
TSB can be doubled to increase the amount of pressure |
|
|
Term
| Types of equipment used for compression therapy |
|
Definition
Ace wraps
Coban
Tubular Support Bandage
Pressure Garments
Transparent Facemask
Neck appliances
Silicone gel sheeting
Inserts |
|
|
Term
| Custom made pressure garments |
|
Definition
have been shown to exert anywhere from 8 mm Hg to 40 mm Hg - still need more research to determine optimal pressure
can be fit when pt. still has a few small open areas
need to be worn 22-23 hrs/day for up to 1 year |
|
|
Term
|
Definition
if pt. has a few open areas, nylons can be worn under the garments to keep non-adherent gauze in place. Make sure there are no wrinkles in the nylons.
Always don garments distal to proximal to prevent edema in distal extremity
Always remove garments proximal to distal |
|
|
Term
| Transparent facemask vs. Spandex |
|
Definition
Pt's need to be more compliant with tranparent masks vs. spandex masks
Spandex masks do not provide adequate pressure on nasolabial folds & cheeks
Children less than 1 year old should not wear rigid masks because they may alter facial bone growth |
|
|
Term
| Creating transparent facemask |
|
Definition
negative mold is taken of patient's face using silicone elasotmer & plaster
Plaster poured into negative mold and a positive impression of the patients face is achieved
A high temperature plastic is heated and stretched over the positive mold |
|
|
Term
|
Definition
Soft cervical collar
Neoprene neck collar
Watusi collar
Aliplast neck brace
Hard plastic neck brace |
|
|
Term
|
Definition
mechanism still being investigated
- increases pressure under garments to help flatten scars
- appears to soften scars
- minimizes pain/itching
Disadvantages
- can cause skin irritation
- should not be worn over open areas
- most are expensive
- short lifespan
Examples: Mepiform, Novagel, Oleeva fabric & foam, Silon SES |
|
|
Term
|
Definition
| used to improve pressure to concave areas or areas that need more pressure in general - can be made out of foam, silicone elastomer, 50/50 putty, or soft putty elastomer |
|
|
Term
| How to tell if a burn pt. has been non-compliant with compression therapy |
|
Definition
scars are red, raised, & firm
scars are usually sensitive to touch & itchy because patient or caregiver has not massaged |
|
|
Term
| Anti-deformity positioning: Anterior Neck |
|
Definition
neck EXTENSION
no pillow
shoulder roll
short mattress
foam wedge |
|
|
Term
| Anti-deformity positioning: Ears |
|
Definition
keep pressure off ears
head in neutral |
|
|
Term
| Anti-deformity positioning: Shoulders |
|
Definition
Abduct at 90 degrees, 24 hours/day
slings or splints |
|
|
Term
| Anti-deformity positioning: Circumferential arms |
|
Definition
Extend elbows & supinate
Bedside tables
Splints
Velcro arm immobilizer |
|
|
Term
| Anti-deformity positioning: Dorsal hand |
|
Definition
"safe position": wrist extended at 30 degrees, MCP's flexed at 60 degrees, IP's extended
Kling roll in palm (2 for larger hand)
hand splint
work to keep thumb out (maintain web space), even in the presence of eschar & swelling |
|
|
Term
| Anti-deformity positioning: Palms |
|
Definition
extend palmar surface
wrap Kling roll to back of hand
palmar extension splint |
|
|
Term
| Anti-deformity positioning:Anterior hips |
|
Definition
Extend with neutral rotation
towel roll under buttocks
bed in reverse Trendelenberg |
|
|
Term
| Anti-deformity positioning: Perineum |
|
Definition
Abduct legs, keep neutral rotation
Place pillow between legs
Use blue foam abduction wedge |
|
|
Term
| Anti-deformity positioning: Posterior leg |
|
Definition
extend knees
knee immobilizer
keep bed flat or in reverse Trendelenberg |
|
|
Term
| Anti-deformity positioning: Ankles |
|
Definition
neutral position
heels off the bed
footboard
multipodus splint
fabricated foot splint
pillows
velfoam strapping |
|
|
Term
| Indications for Splinting |
|
Definition
1. Protection of anatomic structures
2. Preservation of skin graft integrity
3. Prevention of deformity
4. Restoration of function |
|
|
Term
| 3 most important factors in splinting of burns |
|
Definition
Always check fit of splint after fabrication either later that day or the next day
Observe skin integrity daily
Fabricate & apply multiple splints distal to proximal |
|
|
Term
| Exercises to do with burn patients (4) |
|
Definition
|
|
Term
|
Definition
Begin on the day of admission, if pt. is able, especially to establish whether or not pt. has active DF and/or wrist extension
2-3 x/day
Continue until scar maturation |
|
|
Term
|
Definition
Begin on day of admission
Resume on POD 5, if graft is stable enough
Perform at least 2x/day
Massage before and during AROM
Continue until scar maturation |
|
|
Term
|
Definition
Begin on day of admission
Resume gentle PROM on POD 5 if staples are out, and graft will tolerate
Perform 2-3 times per day
Massage before and during PROM
Perform multiple joint stretching
Continue until scar maturation |
|
|
Term
| Resistive Exercises/Strengthening with burn patients |
|
Definition
Perform when graft reaches tensile strength
Perform 1-2x/day
Manual resistance can allow the therapist to grade their resistance and allow the patient to succeed |
|
|
Term
| Resistive Exercises/Strengthening with burn patients |
|
Definition
Perform when graft reaches tensile strength
Perform 1-2x/day
Manual resistance can allow the therapist to grade their resistance and allow the patient to succeed
Important to strengthen all muscles but if it is a constracture, focus strengthing muscles opposing the scar tissue |
|
|
Term
| Ambulation with burn patients |
|
Definition
Patients with partial thickness burns that probably will not need grafted should walk as soon as medically stable
Ace wraps may be needed to minimize swelling
Second degree burns on plantar foot: add adhesive foam to cast shoes for comfort
Full thickness burns: assess to see if exposed tendons can handle forces of walking
Double ace wraps to increase venous support
If an escharotomy is present then follow hospital's policy
POD 5 - ambulate if grafts above knee
POD 7 - ambulate if grafts below the knee
POD 10 - ambulate if grafts are on plantar foot |
|
|
Term
| Tilt table use with burn patients |
|
Definition
Tilt table should be used for early WB
vital signs should be monitored
Get baseline BP prior to ascending (assess mean BP as well)
Begin by inclining to 15 degrees after 3 min., take BP
If systolic remains with 20 mm Hg of the original systolic pressure - safe to ascend more - mean BP should not exceed 100 for children
If patients systolic drops by 15-20 mm Hg then do not ascend & wait another 3 minutes
If pt. stabilized then ascend 15 degrees - After 3 minutes take a BP
Repeat as tolerated - continue to take BP every 3 minutes even after you stop inclining
Follow same steps when descending |
|
|
Term
| Helpful tilt table hints with burn patients |
|
Definition
To strengthen LE's against gravity and mimic walking, undo the knee strap at 20-30 degrees - while holding one knee to prevent buckling, assist patient by lifting the other leg as though they are taking a step - march as tolerated in place
Strengthen UE by tossing a beach ball overhead, play frisbee with cuff weights on arms or practice writing skills while on the table |
|
|
Term
| Use of standing frames with burn patients |
|
Definition
Good to use on small patients who have difficulty wb through their LE due to fear or anxiety
The frames are usually mobile so patients can have a change of scenery
Can distract children by playing with a ball or toys will help
Once pt. feels comfortable on own two feet can progress to walking |
|
|
Term
| Burn pt.'s only d/ced with a w/c if... |
|
Definition
| they are awaiting BLE prosthetic training at a local hospital |
|
|
Term
|
Definition
Pt's need to be able to walk 150+ feet, go up & down stairs with a handrail and walk on various surfaces safely at discharge
Need to have caregivers demonstrate independence with care
ALL disciplines check off caregivers |
|
|
Term
| Reason for ADL's with burn patients |
|
Definition
Improve self esteem
Improve strength & endurance
Improve AROM |
|
|
Term
| Unique to burns when performing ADL's |
|
Definition
watch skin integrity while assisting in transfers, making adaptive equipment, etc.
Must have 120 degrees of elbow flexion to reach your mouth
Must have 90 degrees of knee flexion to walk on stairs |
|
|
Term
| Psychosocial adjustments burn pt's make |
|
Definition
School re-entry
D/C outings
burn camps
Phoenix society
Grief & loss resources |
|
|
Term
| Topics to discuss with school re-entry of burn patients |
|
Definition
how patient got burned
details of hospitalization
exercises
appliances
functional abilities
photo of patient |
|
|
Term
| How a school re-entry session will go |
|
Definition
student won't be there - show picture
have a contact person to help establish a schedule, provide technical supplies, and be your resource person
the younger the children the smaller the group
establish empathy
have children practice what to say to the burned classmate |
|
|
Term
| D/C outings for burned patients |
|
Definition
reintegrate the burn survivor into the community
gives an indication of the psychosocial or physical tasks that need to be improved upon
each pt. should be able to establish eye contact & speak to others
practice how to handle someone who stares and ask questions
Physcially handle situations - stairs, paying for food, etc.
Instruct pt. to rehearse response - polite & quick works well |
|
|
Term
|
Definition
adapts children to physically challenging activities to the individual needs of the child
to improve self-confidence by successfully completing new activities
to share common experiences and tribulations with other burn survivors |
|
|
Term
| Support group for burn survivors of all ages |
|
Definition
|
|
Term
| Grief & Loss Resources for Children |
|
Definition
Dougy Center
Center for Limb Differences in Grand Rapids, MI |
|
|
Term
| D/C Planning for burn patients |
|
Definition
Compliance book - photo album of compliant vs. non-compliant patients
Mental health counseling
Respiratory or med. equipment needed in home
home health nursing
parenting classes
Vocational training
Pictures of every area of the body - each pt. & fam hears an individualized talk dep. on where they were burned |
|
|
Term
|
Definition
| Hard to find a therapist with burn experience - prior to discharge give a phone contact, written info about HEP, video, etc. |
|
|
Term
| Wrote the Lymphadema bible |
|
Definition
|
|
Term
| Resources for patients with Lymphadema |
|
Definition
NLN (Nat'l Lymphadema Network
LANA (Lymphadema Association of N. America) |
|
|
Term
| How to become certified to treat lymphadema |
|
Definition
| go to a course (140 hours) & sit for a board - if you pass the exam, considered "LANA certified" |
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Term
| Brief history of lymphadema |
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Definition
460-377 B.C. - Hippocrates - "vessels w/ white blood"
384-322 B.C. - Aristotle - vessels w/ colorless fluid
1622 - Italian G Asselli - re-discovered lymphatics
1651 - J. Pequet - described structures - cisterna chilae & thoracic duct
1651 - Rudbeck - lymphatics around organs - liver
1652-3 - Bartholin - gave lymphatics its name
1810 - 1890 - Sappey - subcutaneous mercury injections to graph the lymphatic system |
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Term
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Definition
A - carry oxygenated blood from the heart to the capillaries
Veins carry deoxygenated blood back from tissues to the heart |
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Term
|
Definition
transport oxygen & nutrients to tissues
carry immune cells (lymphocytes) to fight infections |
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Term
|
Definition
carry deoxygenated blood back to the heart
act as a reservoir for blood |
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Term
| Functions of capillaries on arterial & venous end |
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Definition
arterial end - ultrafiltration - oxygen rich fluid and proteins leave the bloodstream for the tissues (in the interstitium)
venous end - reabsorption - oxygen poor fluid returns to the bloodstream (transient effect) when the tissue hydrostatic pressure is high |
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Term
| Function of lymph vessels |
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Definition
| carry excess protein-filled fluid back to lymph nodes via lymph vessels (from here back to venous system) |
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Term
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Definition
| filters lymph to rid of antigens and recycles fluid back into venous system |
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Term
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Definition
| filters lymph to rid of antigens and recycles fluid back into venous system |
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Term
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Definition
| Neck, inguinal region, axillary region |
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Term
| Theories on reabsorption of excess fluid |
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Definition
Initially thought venous end of capillaries reabsorbed most of the fluid - now think that lymphatics take most excess tissue fluid and venous end of capillaries are the backup
- fluid swelling onset is quick w/ a lymphatic obstruction but occurs over a long time w/ venous insufficiency |
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Term
| Components of microcirculation |
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Definition
Capillaries
Tissue channels
Proteolytic cells (macrophages)
initial lymphatics |
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Term
| Blood capillaries - makeup, function |
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Definition
single layer of endothelial cells (with a basement membrane) joined in tight or narrow junction - of which most substances leaving capillaries travel
vesicles make up 35% of cytoplasm of the endothelia
- PRO & fluid can move slowly across the cell in the vesicles
- fluids and small molecules and ions can move through the close junction |
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Term
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Definition
Sol state - moving fluid
Gel state - collagen, elastin fibers, ground substance - hyaluranon and other proteoglycan molecules |
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Term
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Definition
space where fluid can move through the tissues (sol state vs. gel state)
form a continuous network of passageways over the whole body
drain into initial lymphatics at very short distances (every 10-50 microns)
act as "pre-lymphatics" in regions where there are no lymph vessels (retina and brain) |
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Term
| Fluid movement through the tissue channels |
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Definition
Hydrostatic pressure - in most tissue channels, tissue hydrostatic pressure (THP) is negative
THP is higher at encapsulated organs
THP is higher during edema
Vibration/changes in TTP |
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Term
| 2 mechanisms that move fluid OUT of tissue channels |
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Definition
Total tissue pressure changes (TTP)
Colloidal osmotic pressure (COP) |
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Term
| Changes in total tissue pressure |
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Definition
TTP is sum of gel & sol pressures
varies
can be influenced by external pressures
can be caused by stretch, massage, movement, exercise, respiration, peristalsis, arterial pulse, & increased fluid in tissues |
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Term
| Colloidal osmotic pressure |
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Definition
| ability of protein molecules to draw fluid from areas where they are in greater concentration to areas of less concentration |
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Term
| Role of macrophages in lymphatic system & location |
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Definition
break down proteins in tissues through proteolysis & help fluid move more easily through the channels to be returned to the circulatory system
- store particles that cannot be broken down
- carry antigens to lymph nodes to alert immune cells
help destroy antigens
Location: originate in bone marrow, travel in blood as monocytes, some lodged in lymph nodes, majority found in interstitium |
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Term
|
Definition
lie just under skin
form a mesh
have small finger-like projections
found near capillaries
fluid & plasma proteins leak from capillaries into tissues & initial lymphatics pick up fluid & plasma PRO as well as waste products |
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Term
| Histology of initial lymphatics |
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Definition
resemble venous end of capillaries by having single layer of endothelial cells
Different in that have many "openable junctions" - made of overlapping endothelial cells
microfibrils connect the endothelial cells to the elastin in the connective tissue
overlapping endothelial cells create one way valves - no back flow
openings allow fluids & large solutes (ex. PRO) to enter the lymphatic system |
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Term
| How fluid enters initial lymphatic (3) |
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Definition
change in TTP
flaps of initial lymphatics open
fluid enters |
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Term
| TTP & fluid movement with lymphatic system |
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Definition
Fluid enters initial lymphatics when TTP is low
Fluid moves on to collectors when TTP is high |
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Term
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Definition
| increased THP holds flaps of inital lymphatics open & more fluid will enter |
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Term
| 2 fluid exchange mechanisms with lymphatic system |
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Definition
| diffusion (permeability) & pressures (Starling's Law) |
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Term
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Definition
Pressure pushing fluid away (Hydrostatic pressure) - BHP (Pressure in aa. moving to tissues), THP (pressure in tissue channels)
Pressure pulling fluid towards - BCOP (higher towards venous end of capillary), TCOP |
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Term
| increase in BHP & decrease in BCOP |
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Definition
| more fluid in interstitium - less uptake by venous capillaries - settles in nearby tissues as edema |
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Term
| Coefficients used with lymphatic system |
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Definition
| filtration permeability coefficient Kf - more permeable vessel walls are - larger coefficient Reflection coefficient σ - reabsorption back into system - values are 0-1 - as pores decrease in size, σ becomes larger At 1, no pores exist and no PRO molecules can get out At 0, all proteins can travel freely The average value is approximately .7 - closer to no pores existing on the venous end - lymphatics important because venous capillaries not able to take up a lot of fluid & PRO |
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Term
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Definition
Ksubf(BHP-THP) - σ(BCOP-TCOP)
ultrafiltation - reabsorption
net fluid flow = lymph obligatory load
To maintain equilibrium, lymph uptake must equal net fluid flow - net fluid flow also affected by proteolysis |
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Term
| Pressures in blood capillaries & tissues during ultrafiltration & reabsorption |
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Definition
arterial end of capillary - BHP high
In tissues - THP low (negative) - fluid pushed out into tissues (ultrafiltration) - THP starts to rise - slows ultrafiltration & increases uptake by lymphatic system (some will be taken back up at venous end of capillary (reabsorption) - PRO slowly leaking out of capillaries via vesicles & smaller ones carried out in fluid flow (bulk flow)
Venous end of capillary - BHP decreased - BCOP increased (plasma PRO hold onto remaining fluid) - ultrafiltration ends) |
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Term
| Tissue proteins with lymphatic system |
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Definition
Proteins cannot get back into the capillaries at the same rate they leave
Macrophages carry out proteolysis
Proteins are also moved by fluid flow into the initial lymphatics |
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Term
| Recent research by Levick |
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Definition
indicates reabsorption at venous end of capillary is transient - most excess fluid from tissues absorbed by lymphatics
Normal tissue osmotic pressure (TCOP) higher than BCOP - wants to keep fluid in the interstitium and doesn't let the capillaries reabsorb much fluid |
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Term
| Lymph or venous system - backup? |
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Definition
| Lymph system takes in about 90% of excess fluid in interstitium, while venous end of capillary does about 10% - venous end of capillary (reabsorption) backup to lymph system |
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Term
| If Starling forces are disrupted... |
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Definition
body has other forces and safety factors to adjust to try to get the body back into equilibrium
ex. Increased fluid in tissue leads to decreased ultrafiltration, increased lymph flow, & transient increase in reabsorption
Decreased concentration of proteins allows for more reabsorption
Macrophages to break down proteins leads to more reabsorption & less ultrafiltration |
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Term
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Definition
| solid-hard - typically NOT painful - probably annoying and uncomfortable |
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Term
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Definition
| Sudden onset of B/L extremity swelling, pain, paresthesia, paresis or paralysis, skin changes, dilated superficial veins |
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Term
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Definition
| +: Grab skin & it's so hard you can't even move it |
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Term
| How to measure lymphadema |
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Definition
Ex. Hand - take base girth at every digit, @ MC, & up every 5 cm - use styloid process as landmark
OR can use volumetric measurements - measure the amount of water displaced |
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Term
| Lymphadema & risk of infection |
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Definition
No longer have good skin nutrition with lymphadema - prone to infection
Excess protein combined with infection causes shape changes - elephantiasis |
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Term
| Characteristics of lymphadema in distal extremities |
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Definition
| "sausage fingers & sausage toes" - have a characteristic appearance |
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Term
| Primary vs. Secondary lymphadema |
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Definition
Primary - born without a competent lymphatic system; genetic - could have too big or too small lymphatic structures; could also be born WITH lymphadema
Secondary - some trauma to an area (ex. car accident or surgery - post mastectomy); most common in the world - parasitic - Filiariasis (mosquito born parasite affecting third world countries) |
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Term
| Onset & presentation of lymphadema in primary & secondary |
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Definition
primary - starts distally & usually U/L
secondary - starts proximally initially & works its way distally with gravity - could be B/L |
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Term
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Definition
| fungal growth - changes the shape of the skin |
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Term
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Definition
| debulking surgery - after years of unmanaged lymphadema, have a surgical procedure to remove excess skin |
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Term
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Definition
| NO - lymphadema is a lifelong problem & requires daily management |
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Term
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Definition
| radiation gets good & bad cells - causing scarring |
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Term
| areas drained by axillary & inguinal lymph nodes |
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Definition
axillary - drains umbilicus up to neck & some back areas
inguinal - drains the umbilicus down to the groin & some back areas |
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Term
| Watershed areas & lymph drainage |
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Definition
| hypothetical line down mid-sagittal plane of body & transverse cut - have anastomoses at these areas - can change the direction of flow across watershed areas - ex. Breast CA - direct flow towards healthy axillary node across the back |
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Term
| 3 main purposes of the lymphatic system |
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Definition
| immune defense, transport of fatty acids, & drainage system |
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Term
| Substances that make up lymph |
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Definition
| protein, water, cells, & (lymphatic loads) |
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Term
| Lymphatic system components (5) & Flow of lymph through body (6) |
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Definition
Microcirculation: Initial Lymphatics
Precollectors
Superficial & Deep collectors
Perforating Vessels - travel similarly to aa. & vv.
Visceral - organs can be affected, but PT doesn't treat this aspect
Lymph flow:
Microcirculation (initial lymphatics)
Pre-collectors
Deep vessels
Lymph nodes
Thoracic Duct/R Lymphatic Duct
L & R venous angles (Back to venous system) |
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Term
| Function of anchored filaments in lymph capillaries |
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Definition
| increased interstitial fluid accumulates & the tissue pressure increases - stretched anchoring filaments will cause a pull on the endothelial cells resulting in an open junction between the cells |
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Term
| Anatomical structure of bigger lymph collectors |
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Definition
| similar to that of blood vessels (intima, media, & adventitia) |
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Term
| Anatomical structure of bigger lymph collectors |
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Definition
| similar to that of blood vessels (intima, media, & adventitia) |
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Term
| Lymph angions & what happens if they don't work - what can help |
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Definition
help push fluid through structure (like smooth m.) - moves 1 direction - another complication of edema - if fluid can't move forward and chronically pushes on valve, lymph angions don't contract any more
external pressures can help with this |
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Term
| Lymph drainage in head & neck |
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Definition
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Term
| Thoracic duct & R Lymphatic duct - what they drain |
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Definition
Thoracic duct - drains LUE & head & neck, BLE
R Lymphatic duct - drains RUE & R head & neck |
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Term
| Mammary gland drainage sites & potential problems |
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Definition
drains into axillary lymph nodes, parasternal areas, & supraclavicular lymph nodes
- Radiation in these areas could affect the brachial plexus, resulting in paresthesia, pareses or paralysis in the UE |
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Term
| sentinel node & sentinel node biopsy |
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Definition
sentinel node - 1st node a specific quadrant drains into
Sentinel node biopsy - common following breast CA - look at dye & which node it enters first & see where CA has spread - hopefully only have to take one node, but usually need at least 2-3
Less nodes you take doesn't mean that you won't have lymphadema - even if you just take the sentinel node, the patient can still get lymphadema |
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Term
| Latent stage of lymphadema |
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Definition
TC of lymphatic system is reduced but still able to cope with normal amount of Lymphatic Load - could occur as a result of lymph node dissection - A reduction in TC can be also caused by dysplasia (congenital malformation of the lymphatic system )
If TC drops below LL, then clinical lymphadema will result
Pt. not currently symptomatic, but still has lymphadema and could be triggered by a small stimulus - no needle sticks or BP on an affected arm w/ radiation or node dissection EVER - could trigger lymphadema |
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Term
| How the UE drains & what happens with Breast CA |
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Definition
The UE drains for the most part into the axillary lymph nodes - part of the lateral upper arm may also drain into supraclavicular lymph nodes (cephalic bundle or "deltoid system")
In case of breast CA with dissection or radiation (or a combination of both) the drainage of lymph from the UE will be impaired - Could cause an accumulation of lymph (pro & water) in the arm resulting in secondary lymphadema |
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Term
| Way we expect lymph to move - what to do with this info |
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Definition
expect fluid to shift to the next set of chain nodes - DON'T do anything on affected side
- move fluid around the back of the elbow rather than to the anticubital fossa & up on affected nodes
- start proximal and move fluid towards head & neck - do same in LE - avoid nodes on affected side & move away |
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Term
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Definition
| LE drains into inguinal lymph nodes - lymph nodes are located in the medial femoral triangle outlined by inguinal ligament, (proximal border) sartorius (lateral), and gracilis (medial) |
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Term
| Most common reason for onset of lymphadema in LE |
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Definition
| congenital malformations of the lymphatic system resulting in primary lymphadema |
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Term
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Definition
| equal to max lymph time volume (amount of lymph the healthy lymphatic system is able to transport utilizing its maximum frequency and amplitude) |
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Term
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Definition
| amount of lymphatic Loads transported by the lymphatic system in a unit of time (ex. LTV of thoracic duct - approx 2-3 liters in 24 hours) |
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Term
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Definition
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Term
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Definition
| If the lymphatic system reacts to an increase in lymphatic load with an increase in lymph time volume |
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Term
| Normal relationship of TC, LL, & LTV |
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Definition
| TC of lymphatic system is much higher than the actual Lymphatic Load - enables lymphatic system to react to an increase in Lymphatic Load (water or PRO & water) with an increase in Lymph Time Volume - ex. more lymph enters the lymphatics causing an increase in contraction frequency of lymph angions |
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Term
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Definition
increase in LL, resulting in increase in LTV (Safety factor) - if LL exceeds TC of healthy lymphatic system, fluid will accumulate in the interstitial tissue, causing edema
- often caused by insufficient venous return (CHF, sitting or standing too long, pregnancy)
- MLD & CDT NOT indicated
- elevation, exercises, and compression garment, if indicated are best treatments |
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Term
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Definition
aka Low Volume Insufficiency
Lymphatic System diseased and its reduced Transport Capacity is not able any more to cope with the normal amount of Lymphatic Load - cannot activate its lymphatic safety factor in case on a mechanical insufficiency
- caused by trauma, surgery, radiation, infection, valvular or mural insufficiences, age, obesity, and malformations of the lymphatic system and others - causes lymphadema |
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Term
| Safety Valve Insufficiency |
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Definition
- pt. already at risk - latent stage lymphadema lymphatic water or protein and water load is increased & at same time transport capacity of lymphatic system is decreased (decreased TC & increased lymphatic load) - causes serious swellings
- a pt. suffering from Lymphadema (Mechanical insufficiency) develops an infection or trauma in lymphedematous area - result is increase in lymphatic loads
- stress proper skin care & precautions to prevent infection - sunscreen, etc. |
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Term
| List the causes & what happens with Primary lymphadema |
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Definition
congenital malformations of the lymphatic system and can be present at birth or develop some time during the course of life
Causes aplasia (absense of certain lymph structures), hypoplasia, hyperplasia, agenesis (not developing lymph structures), fibrosis of lymph nodes
<35 years of age (lymphadema precox)
>35 years of age (lymphadema tardum) |
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Term
| Causes & what happens with Secondary Lymphadema |
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Definition
| Obstruction of lymphatic pathways is caused by a known pathological condition: dissection or radiation of lymph nodes, trauma, chronic inflammations of lymph vessels/nodes, malignant tumors can block lymphatic pathways, blockage of lymphatic & venous return mostly with rubber bands or bandages by the patient (self-induced) |
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Term
| Some triggers for the initial onset of lymphadema |
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Definition
| Hot pack, agressive massage, change in pressure, insult to skin integrity, & changes in weight & body fluid volumes |
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Term
| Lymphadema = Progressive Condition - Implications? |
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Definition
Lymphadema goes through stages - Sooner or later lymphadema Stage I will develop into Lymphadema Stage II.
mykotic & cellulitis attacks are frequent - with infection, Lymphadema tends to develop into stage III. |
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Term
|
Definition
Reversible
Pitting edema; no secondary tissue changes; elevation reduces swelling
Reversible, but not curable - swelling goes away & night with elevation but comes back throughout the day d/t gravity |
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Term
|
Definition
| Hard, fibrosclerotic changes, frequent infection - can be reduced with treatment |
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Term
|
Definition
| increase in volume & texture w/ typical skin changes - have papillomatas & deep skin folds - have lots of infections & cellulitis attacks - full blown elephantiasis - not common in the arms; mostly in the legs |
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Term
| Presentation of benign lymphadema |
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Definition
| U/L; but if B/L is asymmetrical, slow progression; can have brown discoloration with CVI, cyanotic with venous insufficiency, + Stemmer sign, no pain, no paresis/paralysis except with radiation, stroke; dorsum of foot/hand is involved in swelling, deep natural skin folds |
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Term
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Definition
| chronic venous insufficiency - blood not draining & turns brown d/t iron component of blood not receiving effective oxygenation |
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Term
| Use of compression garments with lymphadema |
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Definition
| Only maintain size, doesn't reduce swelling |
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Term
| How to manage drainage through an artifically formed orifice with Lymphadema |
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Definition
| DON'T drain - could lead to infection if orifice is stimulated |
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Term
| Treating lymphadema in CA patients |
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Definition
| DON'T add head or massage to treat - could stimulate more CA growth or metastasis |
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Term
| Treating lymphadema in US vs. Europe |
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Definition
Very different - US late in treating lymphadema
IN Europe, tx more aggressive - see pt's 2-3 hours/day for months with acute lymphadema - in US we can' t afford to do that |
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Term
| Treating pt's with lymphadema in Latent Phase |
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Definition
| education, garments; tell patients about problems with scuba diving, skin care - don't need interventions at this time |
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Term
| Treating patients with Lymphadema Stage I |
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Definition
Start teaching pt's bandaging as soon as possible so pt. can do independently - need to know how to properly rebandage daily
Tx 2-3 wks
MLD 1-2x/day, short stretch bandages, skin care, remedial exercises, pt. ed.
IN PHASE II - MLD if necessary, compression garments, skin care, remedial exercises |
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Term
| Treating patients with Lymphadema Stage II |
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Definition
Tx 3-4 weeks
MLD 2x/day, short-stretch bandages, skin care, remedial exercises, pt. instruction
PHASE II: MLD as needed 1-2x/week, compression garments, bandages at night, skin care, remedial exercises, repeat Phase I (1-2x) |
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Term
| Treating patients with Lymphadema Stage III |
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Definition
Tx for 4-6 weeks
MLD 2-3x/day, short stretch bandages, skin care, remedial exercises, pt. instruction
PHASE II: MLD 1-2x/week, compression garments (in combo with bandages), bandages at night, skin care, remedial exercises, repeat Phase 1 (3-4x), plastic surgery if indicated |
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Term
| Example of remedial exercises in Lymphadema treatment |
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Definition
| bicep curls wearing bandage - helps drain fluid out of area |
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Term
|
Definition
Manual Lymph Drainage (MLD)
Compression Bandaging
Decongestive Exercises
Skin Care |
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Term
|
Definition
| Want to teach pt. to independently bandage and do MLD, but some pt's can't - use Circaids instead |
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Term
|
Definition
Phase I (Intensive): mobilize accumulated PRO rich fluid - initiate reduction of fibrosclerotic tissue (if present)
Phase II: Preserve & Improve success achieved in Phase I |
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Term
| Overall goal of Lymphadema treatments |
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Definition
| Bring pt. back to Latency stage - no signs of visible swelling |
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Term
| 6 Goals of Lymphadema Treatment |
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Definition
Make All Edema Disappear UP
Maintain normal/near normal limb size
Avoid re-accumulation of lymph fluid
Eliminate fibrotic tissue
Decongest Swollen body part
Utilize remaining & intact lymph vessels
Prevent/Eliminate Infections |
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Term
| Characteristics of fibrotic tissue in lymphadema - Stage it begins in |
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Definition
| concentrated proteins in interstitial fluid are treated like foreign bodies - stimulate inflammation & proliferation of CT - combined w/ impaired lymph flow causes metabolic issues & network of fibrotic tissues - changes begin to happen in the latent phase |
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Term
| How diffusion works in lymphatic system |
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Definition
| - gas & lipid soluble substances: dissolve & diffuse - water - diffuse through walls, leave via small pores, close intercellular junctions, fenestrae (when present), open junctions ions & small molecules go through close intercellular junctions, fennestrae, vesicles large molecules can go through fenestrae (another type of vesicle) and open junctions - moved by bulk flow - main avenue via vesicles - affected by molecular sieving (pore size - reflection, blocking pores, wall friction, electrical charge) pressures |
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