-Damage to the integument most commonly results from vascular compromise or trauma.

-Vascular deficiences such as local tissue ischemia (pressure ulcers and arterial diseases) and venous insufficiency can create an unhealty environment and cause skin breakdown.

-ETIOLOGY of the wound provides insight into prognosis.

-Patients with wounds caused by arterial disease usually require surgical intervention to improve circulation which eventually improves healing of the associated skin wound.

-Electrical injuries should lead to suspicion of tissue deeper than the skin has been damaged.

-Types of conditions : VASCULAR COMPROMISE, TRAUMA, AND DISEASE.

-ARTERIAL INSUFFICIENCIES: most commonly situated on the foot, but may occur in other locations.

-Caused by primary loss of vascular flow to an anatomical site, whichleads to tissue death.

-VENOUS INSUFFICIENCY: generally in the lower portion of the leg and can lead to ulceration of the skin.

-Venous stasis may result from venous hypertension, venous thrombosis, varicose veins, or obstruction of a portion of the venous system.

-Precise cause of ulcers caused by venous stasis has not been determined.

-FIBRIN CUFF FORMATION is one theory- caused by increased capillary leakage of fibrinogen as a result of venous hypertension.

-WHITE CELL TRAPPING – venous hypertension decreases capillary flow and removal of WBC. Trapped cells occlude capillaries leading to ischemic damage.

-PESSURE ULCERS: pressure on tissue causes ischemia, producing damage, tissue hypoxia, and death, and pressure ulcers

-Only a few hours of pressure can cause severe tissue injury. -Occurs over bony prominences such as sacral/coccygeal area, ischial tuberosity, heel, lateral malleolus, and greater trochanter.

-Table 12-1 sites at risk for pressure ulcers.

-Inactivity and immobility increase the risk of pressure ulcers.

-Shearing may result from sliding patients from one bed to another.

-Exposure to moisture increases risk of ulcers.

-Age related changes like decreased vascularization and increased protuberance of bony prominences amplify risk of pressure ulcers.

-NUROPATHIC (NEUROTROPHIC) ULCERS:

-Ischemic injury can take place as a result of loss of sensory feedback.

-An ulcer secondary to insensitivity is called a neuropathic ulcer.

-Decreased sensation in the soles of the feet caused by diabetes mellitus may result in a patient who may not sense a pebble in their shoe. Blood flow to the area is reduced because of the pebble.

-Pressure ulcers can also be the result of loss of sensory feedback, as in the case of spinal chord injury.

-May also result from motor neuropathy, leading to anatomicaldeformity that cause pressure points.

-ABRASIONS are integumentary wounds caused by scraping away skin through contact with a rough object or surface.

-AVULSION INJURIES include those injuries which much if not all of the skin and generally the subcutaneous tissue are separated from the underlying tissue.

-DEGLOVING INJURIES result from avulsion injuries that occurrs on the hand or foot.

-PUNCTURE WOUNDS is a hole in the skin created by a pointed object. -BURN INJURIES include electrical, flame, chemicals, and scalding.

-ISCHEMIC SKIN DAMAGE may result in truama from loss of sensory feedback.Decreased sensation prevents a person from making appropriate adjustments to damaging situations.

-INFLAMMATORY SKIN DISEASES are usually patchy sites of either acute or chronic inflammation referred to as dermatitis, includes itching and some scaling. Certain viruses can lead to warts or rashes. Bacteria, foreign bodies, and plugged sebaceous glands are causes of acne and other skin abscesses. -NEOPLASTIC SKIN DISEASES (skin cancer) includes basal cell carcinoma squamous cell carcinoma, and malignant melanoma Three most common types of cancer associated with the integument.

-Exposure to sunlight is most common etiology for each of these cancers.

-Wound examination should include a thorough history and physical assessment of the cause, depth, and size of the wound and signs of infection.

-Variations in examination procedures may be applicable to different etiologies.

-The skin adjacent to the wound needs to be examined for any alterations in normal function ( sensation, temperature, hair growth, mobility, pliability) and appearance( texture and color, red for inflammation and bluish for cyanosis or poor perfusion).

-All ulcers, regardless of etiology, should be examined for size and depth.

-Wound size can be charted by three methods: tracing diagram, TBSA estimates and photography.

-Depth of wound is determined via saline injection (known vol- left over saline).

-Depth of wound is also determined by use of wound filler (ie dental alginate displacement of fluid from volumeter).

-Depth of wound is also determined by observation of the observed area: A moist pink or red wound that is hypersensitive and on an even plane with adjacent, uninjured skin is probably a partial-thickness wound whereas in deeper wounds subcutaneous adipose tissue or fascia can often be identified. In wounds that extend beyond defined subcutaneous tissue, muscle, tendon, ligament, bone, and other structures may be visible

-The above are all techniques for assessing the integrity of the integument. In addition, a full evaluation of the patient:Patient’s ability to communicate and comprehend, joint mobility, muscle performance, gait, ventilation and circulation, and sensory tests such as pain.

VENOUS ULCERS:-Wounds caused by venous insufficiency are commonly found in the lower portion of the leg.

-Exudate and edema are present. Commonly irregular in shape. Generally shallow in depth, with red or pink base.

-Edema is a factor in poor wound healing. Mild pain, decreased with elevation.

-Adjacent skin characterized by inflammation, dilated veins, abnormal pigmentation, and induration (hardness, and maybe dry or scaly.

- Pulses associated with venous ulcers are present.

-Vascular compromise consists of Arterial Wounds, Venous Ulcers, Nueropathic ulcers, and Pressure ulcers.

-ARTERIAL WOUNDS: Commonly found on the lower leg, including feet and toes.

-Shape is usually irregular, often deep, with pale wound base.

-Due to diminished circulation, minimal if any exudate is seen-.-Pain is usually severe and generally increases when leg is ellivated.

-Adjacent skin is characterized by skin loss, pallor on elevation, cool to touch, and appears thin and shinny.

- Pulses associated with arterial wounds are weak or absent.

NEUROPATHIC ULCERS:-Usually located on plantar surface of the foot at pressure points orbony prominences.

-Usually bleeds easily unless coupled with arterial insufficiency.

-The shape of the wound is commonly circular, and often deep.

-Because of the sensory neuropathy that led to the wound, theseulcers are usually painless.

-Adjacent skin is sensory deficit, yet otherwise normal appearance.

PRESSURE ULCERS:Located in diverse sites on the body, generally found over body prominences.

-Examine the location, depth, size, which all vary.

-Staging System is used to describe pressure ulcers, provided by US Department of Health and Human Services.

-Staging of an ulcer is based on wound characteristics, mainly depth.- -Figure Here: Criteria for Staging and Pressure Ulcers:

-Once an ulcer is staged, the assigned stage should not change as the wound changes.

-A stage III ulcer does not progress from a stage III to a stage II and then to a stage I ulcer (back-staging).

-Healing is described in terms of changes in size, depth, and other characteristics, when healed, it’s a healed stage III wound.

-Primary medical intervention is initially suggested. Abrasions, lacerations, puncture wounds, avulsion injuries, degloving injuries, and burn injuries, regardless of the cause of the wound.

-Skin Damage from: flame, chemicals, scalding, radiation, and electric current.

-BURN INJURY SEVERITY DEPENDS ON SEVERAL FACTORS: percent TBSA affected, location of burn, depth of wound, presence of associated trauma ( fracture, nerve injury), and smoke inhalation. ii Figure 12-3 method for calculating percent TBSA and documenting location and dept of wound.

-Percent TBSA and location of burns are good indications of potential impairments and functional loss.

-Impairments may be acute when related to pain or wound contraction in superficial, partial-thickness, and full-thickness burns. -Wounds and scar contracture at a burn site can lead to chronic problems of decreased function and potential disability.

-Location of burns may also have cosmetic implications for long- term socialization.

-Depth of wound can be determined by the presence of certain clinical findings.

-SUPERFICIAL burn injury is painful and erythematous (sunburn-like), with possibility of major localized swelling

-PARTIAL-THICKNESS injuries are typically painful, red, and weepy. Skin is normally pliable. Blistering is also common.

-FULL-THICKNESS burn is generally not painful when palpated. Tan or yellowish-brown, leathery, non-pliable texture.

-ASSOCIATED TRAUMA can increase the severity of a burn injury because of increased impairment besides the burns.

-DOCUMENTATION of associated trauma is essential for determining a plan of care.

-SMOKE INHALATION may lead to cardiopulmonary impairment. The plan of care may require addressing impaired ventilation, gas exchange, aerobic capacity, and endurance related to inhalation injury.

-Physicians carry out diagnosis and primary treatment of skin disease.

-PTs and APTs need to recognize signs and symptoms of skin cancer so that they provide prompt medical referral.

-Key warning signs for skin cancer: new skin growth, a sore that does not heal within 3 months, or a bump that is getting larger.

-Melanoma detection is detected by alterations of growth in the skinor in a mole and may include changes in size, color, shape, elevation, surface appearance, or sensation.

-Assessment of scar tissue may be performed by the Vancouver Burn Scar Scale. -Rates characteristics of scars including: pigmentation, vascularity, pliability, and height. -A higher score correlates with more scarring. -Scars are generally referred to as either hypertrophic scars or keloid scar. Both types experience hypertrophy, but keloid scars extend beyond the boundaries of the wound, hypertrophic scars do not.

-Location of scars need to be assessed for their effect on mobility(over or near joints), and areas of cosmetic importance.

-SCAR CONTRACTION can lead to scar contracture, is a major contributor to wound related disability.