PT final

  1. Dermal Appendages
    -Hair follicles

    -Sebaceous glands 

    -Sweat glands

    lined c epithelial cells-epithelial islands
  2. Epidermis
    Thin stratified epithelium

    –Range from 0.06 to 0.6mm

    –0.4-0.6mm over palms of hands and soles of feet

    –Gives rise to hard keratinized structures (nails, hair)

    • –Cellular, avascular
    • –Composed of 5 layers
    • 90% Keratinocytes (synthesize keratin)
  3. How often does the epidermis shed
    28-30 days

    60 days for ppl 60+ yo
  4. Functions of the Epidermis


    -Vitamin D synthesis


    -Sensation (light touch)


  5. Epidermal-Dermal Junction
    basement membrane: separates epidermis from dermis

    rete pegs
  6. dermis
    Thickest layer of skin

    Provides support and nutrition to the epidermis

    Responsible for giving skin its bulkiness

    Is vascularized and innervated

    Major proteins are collagen and elastin
  7. Functional Components of Dermis
    –hair follicles

    –nerve endings

    –lymph vessels



    –sweat glands

    –sebaceous glands

  8. Acute wound
    planned/unplanned event

    healing proceeds in an orderly and timely fashion


  9. Chronic wounds
    exists 2+ weeks

    does not proceed through normal healing process

    • examples
    • - pressure ulcers
    • -diabetic neuropathic ullcers
  10. normal wound healing phases

    inflammatory phase

    proliferative phase

    maturation phase
  11. inflammatory phase
    • nInitial healing reaction that lasts
    • approximately 4 days

    • nInvolves vascular and cellular
    • responses

    nCellular activity includes:



    –leukocyte migration

    –chemical mediators in place
  12. S and Sx Inflammatory phase



  13. Proliferative phase
    Also known as the collagen phase

    4-21 days

    • Major cell present is the
    • fibroblast which synthesizes collagen

    3 major processes:



    –Wound Contraction
  14. granulation
    healthy red healing tissues
  15. maturation phase
    Also known as the remodeling phase

    • Lasts up to 1 year in a normal
    • healthy adult; up to 2 years in a child, elderly, or immunocompromised patient

    • Tensile strength may increase to
    • 80%

    Abnormal scarring may occur


  16. Hypertrophic scar
    a scar that grows outside the normal boundary
  17. keloid scar
    scar that stays within the normal boundary
  18. types of wound closure
    primary intention

    delayed primary

    secondary intention
  19. dehisced wound
    wound that was closed that re-opened
  20. NSAIDs and wound healing
    –decrease in inflammation

    • –may not be as critical in chronic
    • wounds
  21. steroids and wound healing
    –decrease in inflammation

    • –may not be as critical in chronic
    • wounds
  22. oxygenation is influential in....

    –fibroblast function


    –resistance to infection
  23. wound types








  24. types of vascular wounds
    • arterial
    • venous
    • mixed
  25. Staphylococcus aureus
    Source: individual’s own skin

    healthcare provider's skin
  26. Escherichia coli
    contamination from intestinal contents
  27. Pseudomonas aeruginosa
    intestinal contamination or hospital environment
  28. Indurated
    when skin around it gets hard
  29. necrotizing fasciitis
    Rapidly progressing bacterial infection

    Full thickness skin loss

    Extensive gangrene

    High mortality

  30. Drainage
    • serous
    • serosanguinous
    • purulent
  31. serous
    clear fluid inside the blister
  32. Serosanguinous
    blood tinged inside the serous
  33. Purulent
  34. Pulse Exam
    •0  = no pulse

    •1+ = barely felt

    •2+ = diminished

    •3+ = normal pulse (easily felt)

    •4+ = bounding, aneurysmal
  35. venous filling time
    Indication of arterial system patency

    • Test position: supine, leg elevated
    • to 60°, leg lowered into dependency

    Assess time for veins to refill

    Normal = 10-15 seconds

    Abnormal = > 15 seconds
  36. edema grading scale
    1+ (mild) = 0 - 1/4” pitting

    2+ (moderate) = 1/4 - 1/2” pitting

    3+ (severe) = 1/2 - 1” pitting

    4+ (very severe) = > 1” pitting
  37. Selective Debridement
    –Sharp debridement



    Acoustic therapy
  38. Non-selective Debridement

    • –Physical agents and mechanical
    • modalities

    –Electrotherapeutic modalities
  39. Wound Evaluation: Wagner Classification System
    • Grade 0
    • –preulcerative
    • lesion; healed lesions; presence of bony deformity

    • Grade 1
    • –superficial ulcer without subcutaneous tissue involvement

    • Grade 2
    • –penetration through subcutaneous tissue; may expose muscle, tendon, or bone

    • Grade 3
    • –osteitis, abscess, or osteomyelitis

    • Grade 4
    • –gangrene of a digit

    • Grade 5
    • –gangrene of the foot requiring disarticulation
  40. Gauze Dressing
    Widely used

    • Difficulties encountered:
    • –shedding


    –may slow healing

    • Solutions
    • –impregnated gauze

  41. Biologic Dressings
    Allograft - homograft

    Xenograft- heterograft

    Amniotic membrane
  42. Alginates
    • –composed of polymannuronic
    • acid and guluronic acids obtained from seaweed

    • –produce a hydrophilic gel providing
    • calcium ions into the wound - hemostasis
  43. Alginates: Useful effects
    –moist wound environment

    –high absorptive capacity




  44. Alginates: Indications for use/discontinuation
    • Indications for use
    • –exuding wounds

    –cavity wounds

    –donor sites - hemostasis

    • Indications for discontinuation
    • –minimal exudate
  45. Film Dressings
    • Thin membranes covered with a layer
    • of acrylic adhesive

    • Moisture vapor permeable and oxygen
    • permeable

    Elastic and extensible
  46. Film Dressings: Useful effects
    –moist wound environment

    –autolytic debridement

    • –protection from friction, shear,
    • and microbes

    –transmission of oxygen and moisture
  47. Film Dressings: Indications for use/discontinuation
    Indications for use

    –minor burns

    • –simple injuries (abrasions,
    • lacerations, skin tears)

    –protection over IV sites

    Indications for discontinuation

    –increase in wound exudate

    –wound infection
  48. Foam Dressings
    Produced from polyurethane

    Soft open cell sheets

    Available impregnated with charcoal

    Available with waterproof backing
  49. Foam Dressings: Useful effects
    –moist wound environment

    –high absorbency


    –protection and cushioning


    –provides thermal insulation

    –transmission of oxygen and moisture
  50. Foam Dressings: Indications for use/discontinuation
    Indications for use

    • –minor and major wounds with
    • drainage

    • –may be used as a secondary dressing
    • over amorphous hydrogels

    Indications for discontinuation

    • –when the level of wound exudate
    • requires a dressing change in less than 24 hours
  51. Hydrogels
    • Group of complex polymers having a
    • high water content (30%-90%)

    Two types:

    • –amorphous - free flowing and will
    • easily fill cavities

    –fixed in a thin flexible sheet
  52. Hydrogels: Useful effects
    –moist wound environment

    –autolytic debridement



    –provides moisture
  53. Hydrogels: Indications for use/discontinuation
    Indications for use

    –dry and sloughy wounds to rehydrate

    • –facilitation of granulation and
    • epithelialization

    –simple partial thickness wounds

    • –may be used to prevent drying out
    • of tendons

    –may be used with infected wounds

    Indications for discontinuation

    –excessive wound exudate

    –clinical infection
  54. Hydrocolloids
    • Combination of gel-forming polymers
    • with adhesive held in a fine suspension on a backing of film or foam

    Found as granules, powder or paste

    Form a soft gel mass in the wound

    Occlusive to semipermeable
  55. Hydrocolloids: Useful effects
    –moist wound environment

    –waterproof surface

    • –protection from microbial
    • contamination
  56. Hydrocolloids: Indications for use/discontinuations
    Indications for use

    –superficial wounds

    Indications for discontinuation

    –granulation tissue
  57. primary culture characteristics





    –Religious affiliation
  58. Secondary Culture Characteristics
    –Educational status

    –Socioeconomic status


    –Military experience

    –Political beliefs

    –Urban v. rural

    –Physical characteristics

    –Marital status

    –Parental status
  59. immigration eras
    Open Door – 1776 – 1882

    Selective Exclusion – 1882 – 1910

    Numerical Restriction – 1921 – 1964

    Revolving Door - 1965
  60. Individualistic (low context) cultures [15]
    • Privacy
    • Precise time
    • Future-oriented
    • “Doing”/achieving (task related)
    • Appreciates competition
    • Human equality
    • Promote “self-help” 
    • Informal interactions
    • Direct communication
    • Practicality/efficiency
    • Autonomy
    • Independence
    • Individual credit/blame
    • Common sense and change
    • Youth
  61. Collectivist (high context) cultures [15]
    • Company
    • Loose time
    • Past oriented
    • “Being”/personal growth (non-task related)
    • Appreciates cooperation
    • Hierarchy/rank/status
    • Understands birthright inheritance
    • Formal interactions
    • Indirect communication
    • Idealism and theory
    • The group
    • Interdependence
    • Group credit/blame
    • Order and tradition
    • Elders
  62. Diversity Dimensions



    Sexual Orientation


    Mental/Physical Ability

    Socioeconomic status

  63. L E A R N model




  64. African-American/black
    Communication uses phraseology and rhythmic cadence of expression

    Non-verbal is expressive and animated

    Communication outside the family is limited and family matters viewed as private.

    Formal manners important

    Matriarchal/strong extended family network

    Children valued, older respected

    Prayer/religion important

    Lack of trust for healthcare providers/physicians but respected

    • Traditional/folk
    • practices common
  65. Chinese
    •Submission to authority

    •Extended family/traditional/hierarchical

    •Formal (bow/non-firm handshake)

    •Past oriented


    •Respect for elders

    •Male oriented

    •Non-touch/no eye contact

    •Value silence/quiet

    • •Questions felt as inconveniencing
    • provider

    •Traditional medicine
  66. Latino/Hispanic
    •Closer personal space/touch

    •Respect for authority

    •Formal title

    •“emotional” speech

    • •Traditional family
    • roles/patriarchal/Machismo

    • •Mother primary caregiver/entire family
    • helps make decisions

    •Children valued/don’t like them to cry

    •Value honor, respect, role of elders

    •Illness is god’s will/folk remedies

    • •Appreciate kindness, respect, positive
    • attitude
  67. American Indian

    •Indirect questioning

    • •No steady eye contact, esp
    • w/elders

    •Thoughtful silence

    • •Intuitive, flexible, personal sense of
    • time

    •Gender roles depends on tribe of origin

    •Respect for elders/revered

    •Extended family

    •Spirituality and healthcare inseparable

    • •Health = harmony w/universe, traditional
    • practices

    •Pain is to be endured
  68. Middle Eastern
    • •Conversation verbally and physically
    • expressive

    •Demonstrative w/same gender

    •Men/women avoid direct eye contact

    • •Strict Muslim do not touch opposite
    • gender unless wife (including handshakes)

    •Appointment times are flexible

    •Familial/patriarchal/extended family


    •Traditional practices

    •Pain expressed freely

    •Limited physical contact
  69. Russian/eastern European
    •Family members dependent on each other

    • •“protect” patients – not disclosing
    • pertinent information

    • •Women work full time and take care of
    • household/pride

    • •Stoic about pain/weak to seek medical
    • care



    •Offensive gestures
  70. Factors affecting motivation
    • –Locus
    • of control



    • –Social
    • support
  71. Strategies to enhance motivation
    • –Goal
    • setting

    • –Education
    • & feedback

    • –Peer
    • groups
  72. Generational Differences
    •Builders/Traditionalists (1922–1943)

    –GI Generation

    •Boomers (1943-1960)

    •Busters (1960-1980)

    –Generation X

    • •Bridgers
    • (1980–2000)

    –Generation Y/Millenials
  73. Traditionalists
    •Hard work

    •Dedication & sacrifice

    •Respect for rules

    •Duty before pleasure

  74. Boomers

    •Team orientation

    •Personal gratification


    •Personal growth
  75. Xers

    •Techno literacy

    •Fun and informality


  76. Millenials:

    •Feel civic duty


    •Achievement oriented

    •Respect for diversity
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