PANCE Blueprint Dermatology (5%)

Skin integrity

The NCCPA™ PANCE Dermatology Content Blueprint covers four disorders under the category of skin integrity

Burns

Body percentage:

  • Rule of 9’s: Head 9%, Each arm 9%, Chest 9%, Abdomen 9%, Each anterior leg 9%, Each posterior leg 9%, Upper back 9%, Lower back 9%, Genitals 1%
  • Palmar method: Patient’s palm equates to 1%

Degree involvement:

Treatment: Monitor ABCs, fluid replacement, sulfadiazine. Children with > 10% total body surface area and adults with > 15% total body surface area burns need formal fluid resuscitation

rule9_lg

Lacerations

Suture removal — The timing of suture removal varies with the anatomic site

  • Eyelids – Three days
  • Neck – Three to four days
  • Face – Five days
  • Scalp – 7 to 14 days
  • Trunk and upper extremities – Seven days
  • Lower extremities – 8 to 10 days
Nonabsorbable sutures
Suture material Knot security Wound tensile strength Tissue reactivity Workability Anatomic site
Nylon (Ethilon) Good Good Minimal Good Skin closure anywhere
Polybutester (Novafil) Good Good Minimal Good Skin closure anywhere
Polypropylene (Prolene) Least Best Least Fair Skin closure anywhere. Blue dyed suture useful in dark-skinned individuals.
Silk Best Least Most Best Rarely used
Absorbable sutures
Suture material Knot security Wound tensile strength Security (days)* Tissue reactivity Anatomic site
Fast-absorbing gut Poor Least 4 to 6 Most Face
Vicryl Rapide Good Fair 5 to 7 Minimal Face, scalp, under cast/splint
Surgical gut Poor Fair 5 to 7 Most Face (rarely used)
Poliglecaprone 25 (Monocryl) Good Fair 7 to 10 Minimal Face, consider in contaminated wounds needing deep closure
Chromic gut Fair Fair 10 to 14 Most Mouth, tongue, nailbed
Polyglactin (Vicryl) Good Good 30 Minimal Deep closure, nailbed, mouth
Polyglycolic acid (Dexon) Best Good 30 Minimal Deep closure
Polydioxanone (PDS) Fair Best 45 to 60 Least Deep closure
Polyglyconate (Maxon) Fair Best 45 to 60 Least Deep closure
* Retention of 50 percent of tensile strength.

Most wounds should be covered with an antibiotic ointment and a non adhesive dressing immediately after laceration repair

  • The dressing should be left in place for 24 hours, after which time most wounds can be opened to air.

Prophylactic antibiotics may decrease the risk of infection in some animal and human bites, intraoral lacerations, open fractures, and wounds that extend into cartilage, joints or tendons 

  • Allow animal bites especially in non-cosmetic areas such as the hand and foot to heal by secondary intention

Pressure ulcers

Sacrum and hip most often affected, reposition every 2 hours

  • Stage 1: erythema of localized area, usually non-blanching over the bony surface
  • Stage 2: partial loss of dermal layer, resulting in pink ulceration
  • Stage 3: full dermal loss often exposing subcutaneous tissue and fat
  • Stage 4: full thickness ulceration exposing bone, tendon, or muscle. Osteomyelitis may be present

Wound management by stage of the ulcer

  • Stage I: aggressive preventive measures, thin film dressings for protection
  • Stage II: occlusive dressing to maintain healing, transparent films, hydrocolloids
  • Stages III-IV: Débridement of necrotic tissue. Exudative ulcers will benefit from absorptive dressings such as calcium alginates, foams, hydrofibers. Dry ulcers require occlusive dressing to maintain moisture, including hydrocolloids, and hydrogels.
Pressure ulcer staging. (A) Stage I, erythema; (B) Stage II, breakdown of the dermis; (C) Stage III, full thickness skin breakdown; (D) Stage IV, bone, muscle, and supporting tissue involved.

Pressure ulcer staging. (A) Stage I, erythema; (B) Stage II, breakdown of the dermis; (C) Stage III, full thickness skin breakdown; (D) Stage IV, bone, muscle, and supporting tissue involved.

Stasis dermatitis

Stasis dermatitis is caused by fluid buildup due to varicose veins, poor circulation, or heart disease

  • Skin discoloration of the ankles or shins, itching, thickened skin, and open sores (ulcers) are symptoms

Treatments may include compression stockings and corticosteroid creams as well as treating the underlying condition

  • Systemic antibiotics for patients with more extensive infection and signs of cellulitis

Increased scaling, peripheral edema, erosions, crusts, and secondary bacterial infection on the lower third of the leg in a patient with subacute stasis dermatitis.

Vitiligo (ReelDx) (Prev Lesson)
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