Professional Documents
Culture Documents
● DERMIS (CORIUM)
The dermis is the layer under the epidermis. It contains
nerve endings, blood vessels, oil glands, and sweat glands.
Secondary Lesions
A. Scale
B. Excoriation
C. Erosion
D. Ulcer
E. Fissure
F. Crust
G. Scar
H. Atrophy
I. Lichenification
Primary Lesions
a. Macule: display circular or oval shapes without
elevation or depression; Their borders can be
well defined or fade out into the surrounding.
b. Papule: small, solid elevation of the skin with
diameters less than 5 mm.
c. Nodule: their diameters are normally larger than
5 mm, and they can invade any layer of the skin.
d. Bulla: fluid filled sac or lesion that has diameters
more than 1 cm
e. Vesicle: small blisters less than 1 cm in diameter.
f. Pustule: pus-filled blisters.
g. Cyst: refer to epidermal nodules containing fluid
or semisolid materials.
h. Wheal: are temporarily developed papules or
plaques caused by urticaria or allergic reaction.
i. Plaque: elevated skin with 2 cm in diameter
Secondary Lesions
A. Scales: are aggregates of keratin debris in the
stratum corneum; in psoriasis, scales look white
or silver, and they may appear similar to fish
scales.
B. Excoriation: caused by mechanical traumas or
repetitive scratching to ease pruritus.
C. Erosion: occur by bursting of vesicles in
varicella, variola, impetigo, or herpes simplex.
D. Ulcer: imply skin loss extending through the
epidermis and part of the dermis, which leads to a
breach in epithelial continuity
E. Fissure: linear cleavages of the skin which
sometimes extend into the dermis
F. Crust: dried layers of serum, blood, or purulent
exudate and are composed of bacteria and
epidermal debris.
G. Scar: as a part of the healing processes, replace
the damaged skin tissues.
H. Atrophy: symptom with a decrease in cell size
due to the loss of organelles and substances.
I. Lichenification: a condition in which a part of
the dermis thickens.
H. Vesicle and Bulla
I. Hypertrichosis and Hirsutism
J. Acanthosis Nigricans
K. Acquired Ichthyosis
General diagnosis
➢ Chief Complaint
➢ Past Medical History
➢ Social and Occupational History
➢ Family History
➢ Drug History
Visual Inspection
Changes in Skin Color
➢ Cherry red: carbon monoxide poisoning
➢ Pallor: anemia, fear/shock, lack of sunlight
exposure, arterial insufficiency
➢ Cyanosis: smoking, advanced lung disease,
congenital heart defect, CHF
➢ Jaundice: yellow skin and sclera; liver disease
*carotenemia: yellowish skin d/t excessive
consumption of carotene-rich foods.
➢ Liver Spots: brownish- yellowish spot; aging,
pregnancy, liver/uterine malignancy
➢ Brownish: venous insufficiency
Palpation
Cutaneous symptoms ● Skin turgor test: pinch the skin with two fingers
● Pruritus (MC) then let go.
- an unpleasant sensation that causes an urge to
scratch or rub.
● Pain
- Herpes zoster causes stitching pains along the
nerves and is a typical pain related to the skin
diseases.
- Dermalgia and arthralgia are found in cellulitis
squamous cell carcinoma, malignant melanoma,
lupus erythematosus, systemic sclerosis, and Skin tests with diagnosis supporting devices
polymyositis ● Dermoscopy
● Anaesthesia: absence of sensitivity to sensory - convex lens with 3.5–5× magnification
stimuli - For detailed evaluation of fine wrinkles,
● Hypoesthesia: decreased sensitivity to sensory pigmentation and acne
stimuli
● Hyperesthesia: increased sensitivity to sensory
stimuli
● Tuberculin Test
Used to diagnose tuberculosis and is performed by injecting
● Diascopy a small dose of tuberculin.
- method used for examining brown papule and - > 10 mm= positive
nodule and differentiating the causes of erythema - 5-9 mm = false positive
and purpura. - < 4 mm = negative
- performed by pressuring a transparent, flat, firm
object against the surface of the lesion
● Prognosis
- refers to the process of figuring out the possible
results of a patient’s current status based on the
collected data regarding the treatment of the
patient or other patients with similar symptoms.
● Plan of Care
- a list of suggested intervention methods and their
frequency and duration.
● Intervention
- means various approaches and techniques of
PHYSICAL THERAPY DIAGNOSIS AND physical therapy designed to improve the
EVALUATION METHODS patients’ medical condition.
● Examination
- provides data gathered from medical histories, - Reexamination
systematic reviews, tests, and measurements. - is carried out to detect the changes after the
- It includes the process of collecting data from treatment.
physical therapy evaluation forms, while physical
therapy and intervention are ongoing
● Medical History
- initial information that physical therapists obtain
from the patient interview.
- includes general details gained from history
taking, family history, birth records, past health
status, occupational history, marital history,
pregnancy, menstruation, previous(and current)
illnesses, injuries, surgeries, and medications.
● Systematic Review
- includes the process of evaluating emotional
status, learning type, communication,
communicative competence, and cognitive status
by making an observation on the cardiovascular
system, integumentary system, musculoskeletal
system, and nervous system.
● Assessment
- includes the disease’s progress, phases of
symptoms and signs, stability of the disease and
correlation between the involved system and the
damaged site
subject: INTEGUMENTARY PT
WOUNDS AND WOUND HEALING
● WOUND
○ An injury involving cutting or breaking
of bodily tissue (as by violence,
accident or surgery).
WOUND TYPES
● Acute Wounds
○ Abrasion: caused by a combination of
friction and shear forces, typically over
a rough surface.
○ Avulsion: a serious wound resulting
from tension that causes skin to become
detached from underlying structures.
● Ulcers
○ Incisional wound: most often
○ Arterial Insufficiency Ulcers: occur
associated with surgery; created
secondary to inadequate circulation of
intentionally by means of sharp objects
oxygenated blood.
such as a scalpel or scissors.
○ Venous Insufficiency Ulcers: occur
○ Laceration: a wound or irregular tears
secondary to impaired functioning of
of tissues often associated with trauma.
the venous system resulting in
○ Penetrating Wound: a wound that enters
inadequate circulation and eventual
the interior of an organ or cavity.
tissue damage and ulceration.
○ Puncture: made by sharp pointed object
○ Neuropathic Ulcers: are secondary
as it penetrates the skin and underlying
complications usually associated with a
tissues.
combination of ischemia and
○ Skin Tear: results from trauma to
neuropathy.
fragile skin such as bumping into an
○ Pressure Ulcers: result from sustained
object, adhesive removal, shear or
or prolonged pressure on tissues at
friction forces.
levels greater that of capillary
pressures.
1) Pressure
● A decubitus ulcer occurs frequently to long term
bed-rest patients or wheelchair user 5) Body Temperature and Humidity
● Prolonged pressure over a bony prominence is ● moisture on the skin’s surface acts as a medium
the major cause of developing decubitus ulcer for bacterial growth, the moist skin is subject to
● Pressure greater than 32 mmHg decreases tissue developing decubitus ulcer
resistance and damages soft tissue by impeding ● Higher body temperature results in higher
capillary blood flow. metabolic needs, and when the raised needs are
not sufficiently provided, decubitus ulcer
develops.
Classification
● Pressure Ulcer
A pressure ulcer is clinically called as a bed sore. It is
caused by prolonged and unrelieved pressure over a
bony prominence and eventually results in ischemic
necrosis
6) Malnutrition and Impaired Vasomotor
Response
● Impaired regulation of vasomotion hinders blood
flow, leading to the formation of decubitus ulcer
● Not only is poor nutrition associated with the
failure of healing, but it leads to insufficient
● Diabetic Ulcer
supply of oxygen and nutrition to epidermal
Diabetic ulcer is caused due to the peripheral
tissues, making them vulnerable to decubitus
circulatory disturbance rather than pressure, and it
ulcer
leads to the formation of gangrene on the feet or toes
● The Assessment Tools for Decubitus Ulcer
STAGE SKIN CHANGES TREATMENT
S
ASSESSMENT OF DECUBITUS ULCER
Stage • Skin is in not • Pressure ● Ocular inspection and Palpation
one damaged, but when relaxation ● Observe the shape and the color
pressure is removed, methods ● kinds and the amount of the exudate
erythema does not Turn over ● smell, inflammation or infection
disappear. frequently ● edema, figure out the location and the degree of
•Usually half of the Use tools to
it.
reactive hyperemia relieve pressure
appears when Change ● location of the decubitus ulcer, measure the size
circulatory positions and the depth of it
disturbances occur by
pressure. Reactive ● BRADEN SCALE
hyperemia must be Braden scale is a risk assessment tool made up of six
distinguished from the
indicators: sensory perception, moisture, activity,
stage one of a
decubitus ulcer mobility, nutrition, and friction. Each indicator is scored
1–4 (1–3 for friction) with total score ranging 6–23.
The lower the total score, the higher the risk for decubitus
ulcer. As for inpatients, a score of 15–18, a score
of 13–14, and a score of 13 or lower indicate low risk,
Stage • Loss of fragmentary • Keep in a middle risk, and high risk, respectively. In the case of
two thick skin invaded into moist non-patient elderly, a score of 17 or lower indicates high
the epidermis and environment
dermis. for treatment risk of pressure ulcer
• The Ulcer is • Use normal
superficial, and has saline ● PUSH SCALE
abrasion, herpes, and • Gauze PUSH scale (Pressure Ulcer Scale for Healing scale),
shallow holes. dressings developed by the NPUAP,sorts out the pressure ulcer with
(Improve respect to surface area, exudate, and type of wound tissue,
natural therapy
and each category is scored accordingly
and
interrupt scab
formation) ● PRESSURE ULCER HEALING CHART
Pressure ulcer healing chart, also developed by the NPUAP,
Stage • Loss of the • Debridement allows to monitor and record trends in PUSH scores over
three fragmentary thick skin (necrectomy) time
with necrotic tissues execution
invaded into the • Wet dressing
INTERVENTION
subcutaneous tissue •Surgical
(not into the fascia). intervention ● MEDICAL
• Ulcers are holes in •Proteolytic ● SURGICAL
skin but it doesn’t enzyme ● PHYSICAL THERAPY
affect the
central tissues. ● MEDICAL
• Debridement - Protect the decubitus ulcer and tissue surrounding
(necrectomy) execution
it to prevent an additional injury.
Stage • The complete loss of • Noncontact - Relieve tissue tension surrounding the decubitus
four the skin including dressing ulcer.
necrosis and damages (change every - Protect the area around the decubitus ulcer from
muscles, bones, 8–12 hours) epidemiology stress from the patient’s activities.
tendons, and joints. • Skin graft if - Decrease the virus microbes around the decubitus
• Sinus tract (pupil necessary ulcer.
tract) is a stage four
- Improve the process of decubitus ulcer
decubitus ulcer
management.
- Prevent new decubitus ulcer formation
Tests and Assessment
● Assessment of Decubitus Ulcer ★ DRESSING
➔ Gauze dressing pillow should not make the neck and body bend
- By placing dry gauze after sterilizing the ulcer too much or round shoulders.
area, the gauze dressing absorbs the exudates and - Placing a small cushion under the knees helps to
protects the decubitus ulcer by keeping the ulcer make the patient comfortable and prevent lumbar
area sterilized. lordosis. If a cushion is too big, it may cause
contracture on the iliopsoas and hamstring so the
➔ Wet Dressing long time used should be avoided.
- Keeping moisture of the decubitus ulcer area - To disperse the pressure on the heel, a small
shortens the ulcer’s and soft tissue’s treatment towel can be used, but it should be used carefully
times and it also helps to prevent scars. Choose a to avoid hyperextension.
hydrocolloid, hydrogel, or polyurethane dressing - Don’t let the patient’s arms fall outside of the
depending on the decubitus ulcer’s condition bed; put them next to the body or on the chest
★ MEDICINE
● Injecting antibiotics (bacitracin, polysporin,
neomycin, etc.) is effective to prevent local
infection of the decubitus ulcer.
● To use neomycin, it has to be checked if the
decubitus ulcer patient has an allergic reaction to
it
● Antiseptic drugs are not recommended for a
decubitus ulcer patient because the drugs remain
in the body. ★ Prone
★ Side-lying
★ SURGICAL ★ Sitting
- If the decubitus ulcer’s necrotic tissue is big or
treatment is impossible through dressing, then ● Prone position
surgery is needed (skin graft, fl ap). Surgery for - The prone position makes a patient’s shoulder
decubitus ulcer involves in removing ulcers and and backbone parallel to each other. Patients,
infected bone, trimming the protrusion bone, and who have feelings in their arms or don’t have any
suturing the skin with healthy tissues. problem communicating, put their arms next to
the body or head. But physical therapists should
★ PHYSICAL THERAPY ask the patents if their arms feel numbness or
● POSTURES PREVENTING DECUBITUS become insensitive when they are in the prone
ULCER position for a long period of time. Decubitus
● EXERCISE ulcer can occur or become worse because of the
● MANUAL nerve compression and poor circulation.
● PHYSICAL AGENTS - When a patient is in prone position, put a small
pillow under their head and turn the patient’s
★ Posturing head to one side or put on table with a hole (table
- The posturing of decubitus ulcer patients can with a head hole; Fig. 3.11 ). Armrests and face
prevent deformities and complications of control tables help patients to have a comfortable
decubitus ulcer position because patients can have enough spaces
➢ Supine and supports for their heads. This table is used to
➢ prone keep a patient’s neck balanced (Fig. 3.12 ).
➢ Side-lying - Putting a pillow under a patient’s stomach can
➢ Sitting reduce lumbar lordosis. Putting towels under the
shoulder increases scapular adduction and protect
★ POSTURES PREVENTING DECUBITUS the humerus head by reducing tension on the
ULCER adductor canal between the scapulas. Relax the
- Supine position is lying down with shoulders pelvis and lumbar and reduce the hamstring
parallel to the hips and straight backbones. muscle tension by putting a small pillow or a roll
- Placing a small pillow or a cervical roll under the under the patient’s ankle. But a big pillow may
patient’s head is necessary. The height of the
cause the hamstring muscles to contract by - Use more than one pillow when a patient sits
bending the knees. against the treatment table and let the patient
support the upper part of the body (Fig. 3.14 ).
When the patient has been leaned against the
back of the chair for a long time, put a cushion on
the patient’s back.
- Move the patient’s arms to their knees or onto the
armrests. When patients are sitting for a long
period of time, make them do push-ups holding
the armrests and lifting their hips, move their
upper body to the left and right, or bend their
upper body every 15 min to relieve hip
● Side-lying position compression.
- The side-lying position is a position when the - Using a special wheelchair with a tilt-in-space or
patient is located at the middle of the bed and a reclining back will be more comfortable (Fig.
arranges the head, body, and pelvis. Make the 3.15 ).
patient’s hip and knee joints semifl exed (Fig.
3.13 ).
- Support the upper legs with a couple of pillows
and locate lower legs a little bit to the back. Let
the lower part of the legs support the patient’s
pelvis and lower half of the body.
- Prevent a patient’s upper body from inclining
through supporting the brachial with a pillow in
front of the patient's chest.
- Use a safety belt and a thick pillow when the
patient can’t lie on his side by himself.
- Increase the body’s comfort and safety with the
patient's arm. If protection is needed under the
bony spur concerned with the decubitus ulcer ● Changing Position
development due to the compression, put a pillow Because the continuous compression is the reason of
at the distal end of the limb and put a second decubitus ulcers, change position at least every 2 h when a
pillow under the bony spur. Avoiding the direct patient is lying down and every 15 min when a patient is
compression to the bony spur is the most sitting. When a patient is lying down on their side (e.g.,
important in a long term side-lying position. watching TV), lay down making the body 30° to the floor
Therefore, a side lying position against in any direction following the 30° angle law . Keep a
something should be considered. 30° angle of the patient’s arms, legs, and even head by
using pillows
● Sitting position
- A stable chair needs to be used for patients in the
sitting position. A patient’s foot should rest on
the floor or a prop of a wheelchair. The femoral
buttocks tissue and deep tissue shouldn’t be
compressed from the edge of chairs or the ★ EXERCISE
wheelchairs.
- Exercise therapy for decubitus ulcer focuses on
aerobic exercise and enhancing peripheral
circulation. When a compression decubitus ulcer
has occurred, promote the circulation of ulcer
through increasing a patient’s deep breathing and
enhancing the pump functions of the calf muscle
- exercising by walking on the treadmill or the
ground or riding a stationary bicycle for 15 to 40
min.
- intensity at 60–80 % of their HRmax. ,
- conduct ankle-pumping exercises 20 times a set,
and do two or three sets per day.
- heel raise exercises ten times a set, three sets a
day
★ PHYSICAL AGENTS
★ MANUAL
● Whirlpool Bath Treatment
A decubitus ulcer surgery such as a skin graft or flap leaves
● Ultraviolet Therapy
a scar. A scar will limit the epidermis and subcutaneous
● Iontophoresis
tissue’s mobility through its adherence to the surrounding
● Laser Therapy
tissues. It can cause pain inside the scar. Skin rolling and
scar tissue release are effective ways to relieve pain and
● Whirlpool Bath Treatment
increase skin mobility
- whirlpool bath removes dirty ulcer fragments,
bacteria, exudates, and blood residue, reduces
● Skin Rolling
pain, and stimulates the decubitus ulcer healing
- Physical therapists hold the wounded skin softly
through hydrating the ulcer areas with water
with their thumb and index finger and roll it up,
down, and diagonally When a sutured wound is
● Ultraviolet Therapy
too thick for rolling, hold the skin farthest away
- Ultraviolet radiation is effective to improve
from the wound and roll the skin by moving
immunity by creating Vitamin D while sterilizing
toward the center. Conduct skin rolling in a
the area around the ecubitus ulcer.
variety of ways. However, before conducting the
- destroys decrepit cells, improve regrowth of cells,
skin rolling, remove the skin’s oil from the skin
and boost treatment for the decubitus ulcer by
of therapist and patient, and keep the area clean
causing a crust to form on the necrotic tissue
● Scar Tissue Release
● Iontophoresis
- Ask the patient which sutured wound is the most
- is a drug electrotherapy that passes local
sensitive, and press it with the tip of an index
activating ions to scar tissues of the decubitus
finger. The therapists’ fingers should turn
ulcer by using continuous anode and cathode
clockwise and the therapists should continue to
penetrating into the skin. Iontophoresis has an
ask a patient which sutured wound is the most
anesthetic effect that can reduce pain and
sensitive. At this point, repeat the scar tissue
inflammation on the area of the decubitus ulcer
release to induce a loosening of the tissue through
light compression and retrogression of the tissue
● LASER Therapy
- reduce inflammation, increase prostaglandins’
concentration, boost ATP creation, increase
collagen, and increase fibroblast cells. It also
increases the phagocytosis of macrophages,
activates the immune system, and promotes cell
proliferations by stimulating the absorption of
exudates and a diffusion reaction.
2) Educate the patient to change positions every 2 h
le-g. position change, lift their bottom on a
wheelchair, lift their pelvis in a supine posi-tion,
or lift their body from a sitting position (Fig,
323)],
3) Disperse the pressure through the use of an air
mattress or a water mattress.
4) Protect the area of bone protrusions by using joint
guards and bandages.
5) Take care to not make abrasions on a patient's
skins when changing the mattress sheets or a
patient's position.
6) Establish the early mobilization programs and
practices.