Module eight

The skin contains a variety of appendages, mainly: they are downgrowths (diverticula) of the epidermis into the dermis

- Hair follicles (HF) - warmth and protection - Apocrine (sweat/may have a role in sexual function?) and Eccrine (sweat) glands: aids in thermoregulation by perspiration - Sebaceous Glands - produce sebum (oil to lubricate the skin) - Nails: protection, manipulation of objects

Cellular Components of the dermis

- fibroblasts - macrophages - mast cells - lymphatic glands - blood vessels - nerve fibers

Macrophages

- phagocytizes foreign substances, involved in inflammatory and repair processes

Blood vessels

- provide metabolic requirements for the

Mast cells

- releases histamine for vasodilation and chemotactic factors for inflammatory responses

Lymphatic glands

- removes microbes

Fibroblasts

- synthesizes collagen (vital in wound healing)

high temp: Surface blood vessels will __________ (sweating) low temp: Surface blood vessels will __________ (shivering)

- vasodilate - vasoconstrict

the epidermis has ____ layers and is thickest in the _____ and soles of _____

5 hands feet

P.T. Objectives -- common goals for wounds

Decrease colonization of infectious organisms Soften and remove non-viable tissue Absorb excess exudate and prevent further breakdown Protect wound and promote clean environment Facilitate granulation and epithelialization Increase patient's functional abilities Educate patient and family

The study of the skin is _______

Dermatology

Tx for psoriasis

Topical agents including steroids, oral steroids, and immunosuppressants

subcutaneous tissue

adipose fascia

the epidermis is thin and _______

avascular

Skin Infections can be caused by ________, viral, fungal, or other parasitic sources

bacterial

These germinal cells are separated from the dermis by a thin layer of _____________.

basement membrane

The vasculature is organized so that by increasing or decreasing ______ flow, heat can either be conserved or dissipated. The vasculature ________ in areas called dermal papillae.

blood interdigitates

for SLE, Rash is raised, red and has scaly plaques that can appear anywhere but the "classic" rash is in a ______ ______. Doesn't itch.

butterfly shape

illness for wound healing

chronic illnesses, endocrine, vascular, connective tissue disorders may delay wound healing

Pruritis (itching

common symptom of underlying systemic disease

Scleroderma or Systemic sclerosis is a Diffuse _____ ______ disease that causes fibrosis of the skin, joints, blood vessels, and internal organs. Chronic disease, can be more _______ or widespread throughout the body. _____ etiology, maybe triggered by bacteria.

connective tissue localized Unknown

Topical medications in wound healing

cytotoxic, will delay

the cells of the stratum granulosum are _______.....as are the rest as we move outward.

dead

nutrition for wound healing

deficiency of protein (albumin level), calories, vitamins (C), and trace metals (especially zinc and copper) can delay healing

cellulitis is Inflammation of the _____ and subcutaneous tissues and spreads through tissue spaces. ______ and ______ are the usual cause

dermis Streptococcus or Staphylococcus

The deeper cells of the stratum corneum (SC) retain their________ __________, but as they are pushed to the surface by newly forming cells, the dead cells gradually break apart and are lost, a process called _________.

desmosomal junctions desquamation

The cells that divide in the statum germinativum soon begin to accumulate many ___________(adhesion sites) on their outer surface which provide the characteristic "prickles" of the_________ _________, which is often called the prickle-cell layer.

desmosomes stratum spinosum (SS)

The _______ is the most superficial layer of the skin and provides the first barrier of protection from the invasion of foreign substances into the body.

epidermis

Sx for psoriasis

erythema, plaques covered with scales, itching Common

Xeroderma

excessive dryness of the skin.

The dermis contains mostly _________ which are responsible for secreting collagen, elastin and ground substance (jelly-like matrix) that give the support and _______ of the skin.

fibroblasts elasticity

sx of raynauld's

fingers/toes become white or cyanotic as the blood vessels to the extremities narrow.

Blisters

fluid-filled lesion, occurs due to infection, local injury (burn), medication reaction.

The papillary dermis also contains the______ _____ ______ _____ and sensory receptors

free sensory nerve endings

Tendon

glistening white, fibrous

Joint capsules

glistening white, thin

cellular metabolism produces ______ as a waste product

heat

Fascia

highly fibrous connective tissue separates and surrounds structures an facilitates movement between adjacent structures Deeper lymphatics are also located in subcutaneous tissue

the dermis is ______ ______ to provide nutrition to dermis and epidermis

highly vascular

Adipose tissue

highly vascular, loose connective tissue stores fat, provides energy, cushions, and insulates stores Vit A, D, E, and K

in the dermis__________ ________are present that are involved in the defense against foreign invaders passing through the epidermis.

immune cells

Necrotic tissue in wound healing

impairs wound healing and increases likelihood of infection

Bacterial skin infection

impetigo, cellulitis

The _______ is the _____ organ system and is _______. Largest _____ ______ in the body

integumentary system largest 10-15 lbs sense organ

smoking for wound healing

interferes with oxygenation of tissue

The reticular layer of the dermis consists of dense patches of_________ ____ ____, which differs from the papillary layer, which is made up of mainly loose connective tissue

irregular connective tissue

Integumentary system

is the skin as well as the other accessory components (hair, glands, nails)

After mitotic division a newly formed cell will undergo a progressive maturation called__________ as it migrates to the surface.

keratinization

principal cell of the epidermis?

keratinocyte

These granules contain _____, which along with the desmosomal connections, help to form a ________ barrier that limits fluid loss from the body.

lipids waterproof

The dermis is typically subdivided into two zones: _____ and _____

papillary dermis (outermost) reticular layer (innermost)

stratum germinativum (SG) or stratum basale

provides the germinal cells necessary for the regeneration of the layers of the epidermis.

infection in wound healing

reduces collagen production and kills "good" cells in the wound

Muscle

rich vascular supply, dark red and bleeds easy

Fungal skin infection

ringworm, athlete's foot

Raynaud's Phenomenon can be one of the 1st manifestations of ________ or can be present by itsel

scleroderma

Bone

shiny, smooth, and white/cream color

Ligament

similar to tendon....not as glistening

Thinning skin, immobility, poor nutrition, reduction in adipose tissue, decreased circulation, changes in sensation, medication-induced changes all lead to a higher risk of _____ ______ --> geriatric clients Avoid _____ ______during transfers (slideboards, W/C wheels). Use caution when using _______ Proper positioning is crucial.

skin breakdown shearing forces heat / cold modalties

what is the epidermis plus dermis?

skin-

Pt for those with scleroderma

splinting, ROM, strengthening, functional training, pain management, wound care, etc.

epidermal layer (going from top to bottom layer)

stratum corneum stratum lucidum stratum granulosum statum spinosum stratum basale (statum germinativum) basement membrane dermis

what are the 5 layers or strata of the epidermis?

stratum corneum (SC) stratum lucidum (not clearly seen in this photomicrograph) stratum granulosum (SGR) stratum spinosum (SS) stratum germinativum (SG) or basale

The _____ ________ takes its name from the dark granular pre-keratin material usually seen in its keratinocytes. This material takes the form of aggregated _____________ granules.

stratum granulosum (SGR) keratin-hyaline

the ______ ______ is normally only seen in thick epidermis and represents a transition from the stratum granulosum to the stratum corneum.

stratum lucidum

The reticular layer of the dermis is important in giving the skin it overall ________ and ________, as well as housing structures such as glands and hair follicles.

strength and elasticity

psychological for wound healing

stress, depression, and sleep disorders alter autoimmune response

Functions of the skin

1. Regulation of body temperature 2. protection --> physical abrasion, dehyd., UV radiation 3. sensation --> touch, vibration, pain, temp, pressure 4. excretion 5. immunity/resistance 6. blood reservoir --> 8-10% in rest adult (can be shunted as needed) 7. synthesis of vit D --> produced by UV ray exposure, vit D inc calcium absorption by 30-80%

papillary dermis contains vascular networks that have two important functions -- what are they

1. Supports the avascular epidermis with vital nutrients 2. Provides for a network for thermoregulation

local factors for wound healing

1. infection 2. topical meds 3. dressings 4. necrotic tissue 5. dessication

Risk Factors in Healing --> systemic

1. nutrition 2. age 3. illness 4. smoking 5. systemic meds 6. psychological

General Signs and Symptoms of Skin Pathology

1. puritis (itching) 2. urticaria (hives) 3. xanthema (rash) 4. blisters 5. xeroderma

for raynauld's -- Usually the episode lasts about______ minutes. Painful, after the episode the extremities can be hot and red. Trigger: _____ or _____ what type of modalities should be avoided?

10-15 stress or cold Avoid thermal modalities, esp on extermities

for those with scleroderma, about _____ of those with visceral involvement die within 5 years of onset. and there is no cure.

30%

Skin involvement in about ____ of those with SLE. Sun exposure causes ______ in the skin....unknown etiology.

30-50% flare-ups

Contact Dermatitis

Acute or chronic skin inflammation caused by exposure to a chemical, mechanical (ex/ pressure), physical (ex/ heat), or biologic agent. Common Examples of triggers: nickel (jewelry), latex, topical antibiotics (neomycin), topical anestheics (lidocaine) Itching, redness, edema

Age for wound healing

Advanced age dec wound healing through delayed wound contraction, dec epithelialization, delayed cellular migration, dec rate of capillary growth, delayed collagen remodeling, dec rate of drying and dehiscence

Wound Evaluation --> History

Age and gender Past Medical History Social History --> is someone around to help Medications Allergies Labs - cultures, MRI, X-ray, ABI, blood work Onset of wound and history Prior treatment for wound

SLE (Lupus) is a _____ ______disorder of the connective tissue _______ ______, trigger unknown

Chronic inflammatory auto-immune

Psoriasis is ________, ________, _______ _______ inflammatory disease that is ________ Once it occurs will most likely become _____ (in and out of remission). uncontrolled epidermal division --> intense itching

Chronic, inherited, auto-immune, recurrent Noninfectious chronic

Causes of Skin Lesions

Contact with agent (toxin) Contact with infectious organism Medication rxn. Physical trauma - including burns Hereditary factor Reaction to allergen Reaction to radiation therapy Systemic in origin Neoplasm

systemic meds for wound healing

Corticosteroids, NSAID's, heparin, coumadin, antineoplastic drugs, some systemic antibiotics

Tx for cellulitis

IV antibiotics or surgical debridement of necrotic tissue.

_______ are also in the epidermis and are _________ (lymphoid) immune cells. these cells present _______ in the skin and are vital to the immune response

Langerhans' cells dentritic antigens

_________ are also in the epidermis and synthesize ________ --> a pigment that protects against ______ rays

Melanocytes melanin UV

Atopic Dermatitis

Most common type of eczema Chronic inflammatory disease Affects more than 10% of all children. Clients also tend to have other allergies (food, pollen, etc.) Unknown etiology Presents as a rash, can become infected No cure, but can be controlled with medication

Eczema and Dermatitis

Often these general terms are used interchangeably Superficial inflammation of the skin Staged: acute (red/itchy), subacute, and chronic Most often seen in older clients and children (eczema) Etiology: trigger or unknown

most at risk for cellulitis

Older clients, diabetics, malnourished, steroid therapy, presence of wounds / ulcers

functions of the epidermis

Physical and chemical barrier Regulates fluid Provides light touch sensation Assists with thermoregulation Assists with excretion Vitamin D production Appearance

progression of scleroderma

Progression: Non-pitting edema leading to thick hardened of the skin...leads to decreased flexibility of the joints...and can progress to skin atrophy and ulceration.

Other skin infections

Scabies (mite)

the ______ layer is under the skin

Subcutaneous layer or hypodermis

the dermis also contains superficial ________

Superficial lymphatics

functions of the dermis

Supports and nourishes epidermis Houses epidermal appendages Assists with infection control Assists with thermoregulation Provides sensation

Epidermis varies in_________throughout the body depending mainly on ________ forces and is thickest on the ____ of hand and _____ of feet

thickness frictional palms soles

Tx for SLE Survival rates are increasing....but still can be fatal over time due to kidney and/or cardiac complications.

topical and systemic medication

Xanthema (rash)

usually occurs as a secondary response to some primary agent, ex/ medication reaction

Urticaria (hives)

vascular reaction marked by the appearance of smooth slightly elevated patches (wheals). (TRY IT)

Viral skin infection Other: Scabies (mite)

warts, Herpes simplex (cold sores/fever blisters), chicken pox, shingles

Dressings in wound healing

wet-to-dry on granulating wound? Not advised to use! wet-to dry dressings = saline soaked dressing, waiting for it to dry and then ripping off