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NUR 141 > 1.3b Inflammatory > Flashcards

1.3b Inflammatory Flashcards

1
Q

Inflammatory response definition

A

Sequential reaction to cell injury
Fundamental type of response by the body to disease and injury, a response characterized by the classical signs of redness, edema, heat, pain

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2
Q

Role of inflammatory response?

A

Neutralizes/dilutes inflammatory agent
Removed necrotic materials
Establishes an environment for healing and repair

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3
Q

Inflammation does not always equal infection

INFO

A

Same regardless of injury agent or antigen
Intensity of response depends on extent/severity of injury
Response depends on the reactive capacity of the injured person
Can be local or systemic response; acute or chronic
Systemic- significant role in many disease processes

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4
Q

Inflammation healing:
Acute?
Subacute?
Chronic?

A

Acute: healing
2-3 weeks without residual damage, neutrophils are predominant WBC

Subacute: lasts longer

Chronic: lasts for weeks, months or even years with persistent and repeated tissue injury, predominant BC or lymph’s and microphages. autoimmune disease, rheumatoid arthritis, osteomyelitis

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5
Q

Paradoxically, the inflammatory process?

A

Paradoxically, the inflammatory process itself may cause tissue damage while it is engaged in healing and repair. Thus, inflammation may play a role in such diverse disorders as Alzheimer disease, meningitis, atherosclerosis, cystic fibrosis, asthma, cirrhosis of the liver, inflammatory bowel disease (IBD), diabetes, osteoporosis, and psoriasis.

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6
Q

Inflammatory Response Clinical Manifestations

Local?

A 
Local
Pain
Erythema, heat
Edema
Heat
Change in function
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7
Q

Inflammatory Response Clinical Manifestations

Systemic?

A

Systemic
Increased temp, resp, pulse

Erythema

Increased WBC with shift to left (high neutrophil count)

Vascular response: inflammatory mediators (histamine, prostaglandins, leukotriene) cause vasodilation & Increased capillary permeability. Cytokines cause fever

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8
Q

Wound classification
Cause?
Duration?

A

By cause:
Surgical or nonsurgical
By duration:
acute or chronic (>3 months)

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9
Q

Wound classification

Depth?

A

By depth of tissue affected:

Superficial
Involves on the epidermis

Partial thickness
Wound extends into the dermis

Full thickness
Involves the subcutaneous tissue and may extend into the fascia, muscle, tendon, or bone.

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10
Q

Regeneration?

A

Regeneration: replace lost tissue with same type (liver can rebuild)

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11
Q

Repair?

A

Repair: replace with connective tissue; various types

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12
Q

Repair: Primary intention, Initial phase?

A

Primary intention:
Initial: 3-5d, approximation, migration, fibrin meshwork. inflammatory, wound area fills with blood, clots form and platelets release growth factor area of injury composed of fibrin clots, RBCs, neutrophils, debris. Extracellular enzymes from macrophages digest fibrin. Debris are removed and remaining fibrin meshwork remains.

Maturation & scar contraction: collagen organized/remodeled avascular scar forms

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13
Q

Repair: Primary intention, granulation phase?

A

Granulation: 5d-3wk, fibroblasts, surface pink vascular, edges begin to regenerate & migrate

components of granulation tissue – fibroblasts, capillary buds, WBCs, exudate, and a semifluid ground substance fibroblasts are immature CT cells, secrete collagen which we be structured into fibrous scar tissue surface is pink, full of capillary buds, at risk for dehiscence & resistant to infection. Wound edges begin to regenerate & new epithelium & migrates in a one-cell thick layer until it contacts cells from the other side begins to resemble adjacent skin

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14
Q

Repair: Primary intention, maturation and scar contraction phase?

A

Maturation & scar contraction: collagen organized/remodeled avascular scar forms.
overlaps with granulation phase, can continue for extended period of time (abd surgery restricts lifting for 6 wks) myfibroblasts cause contraction

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15
Q

Repair: Secondary intention

A

Secondary Intention:

  • Type of healing for wounds that have large amounts of exudate, wide irregular margins & extensive tissue loss & edges can’t be approximated
  • Wounds related to trauma, ulceration, and infection
  • Inflammation is more significant
  • Healing and granulation takes place from the edges inward and from the bottom upward; healing process like primary intention but more granulation tissue & scarring
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16
Q

Repair: Tertiary intention

A

Tertiary Intention:

  • Wound contaminated or left open after infection to be sutured later after infection is controlled.
  • Healing occurs with delayed suturing of a wound.
  • Results in a larger and deeper scar.
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17
Q

Factors that inhibit healing

Hemorrhage?

A

Hemorrhage

Hematoma-collection of blood underneath the tissues.

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18
Q

Factors that inhibit healing

Infection?

A

Infection
Signs of infection early, within 2-3 days.
Surgical wound infection 4-5 days.

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19
Q

Factors that inhibit healing

Dehiscence?

A

Dehiscence

Skin and tissue separate due to poor wound healing.

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20
Q

Factors that inhibit healing

Evisceration?

A

Evisceration
Total separation of wound layers with protrusion of visceral organs through wound opening.
Emergency situation that requires surgical repair.
Nurse to place a sterile towel soaked in NS over eviscerated area. NPO status.

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21
Q

Factors that inhibit healing

Fistula?

A

Fistula
Abnormal passage between 2 organs or between an organ and outside of body.
Drainage through fistula increases risk of skin breakdown.

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22
Q

Factors delaying healing

A

Inadequate blood supply= ↓supply of cells & nutrients

Obesity = ↓blood supply

Anemia = ↓oxygen supply to tissues

Infection = ↑inflammatory response & tissue destruction

Smoking = vasoconstriction

Friction = destroys granulation & separates edges

Advance age = ↓immunity, delays in tissue synthesis

Diabetes = impairs phagocytosis, tissue growth, & vascular supply

Corticosteroids =impair WBC & fibroblast function, ↓granulation & contraction

Nutritional deficiencies

23
Q

Nutrition and healing

Vit A, B C

A

Vitamin A
Aids in process of epithelialization.

Vitamin B
Coenzymes for metabolic reactions

Vitamin C
Promotes formation of collagen fibers and capillary development.

24
Q 
Nutrition and healing
Protein (albumin)
Carbs
Fats
Zinc
Fluids
A

Protein (ALBUMIN)
Provides amino acids for tissue repair

Carbohydrates
Increased metabolic energy

Fats
Aids in synthesis of fatty acids and triglycerides.

Zinc
Promotes epithelialization

Increased fluids
Loss from perspiration and exudate

25
Q

Resistant pathogens

A

Multidrug resistant pathogens

MRSA : Methicillin resistant Staph aureus
VRE :Vancomycin Resistant Enterococci

26
Q

Resistant pathogens

isolation

A

Contact precautions

Private room

Hand washing before entry and upon leaving room

Instruct patient, family, and visitors on isolation procedures.

Box 16-2 Lemone – preventing MRSA p.480

27
Q

Nursing Care of Wounds

On admission

A

On admission:
Inspect entire body
Record all wounds and appearance & Measure length, width, & depth

28
Q

Nursing Care of Wounds

Wound care, primary intention healing?

A

Primary intention healing

  • Cleansing- Normal saline best for cleaning wounds.
  • Adhesive strips
  • Steri strips/sutures
  • Transparent film dressing
  • Dry sterile dressing (removed when drainage stops)
  • Medicated sprays with transparent film
29
Q

Nursing Care of Wounds

Wound care, secondary intention healing?

A

Secondary Intention healing

  • Dressing products: (Lemone pg 505 Table 16-2)
  • Clean, prevent & manage infection IRRIGATION
  • Manage exudate
  • Maintain moist environment
  • Protect the wound
30
Q

Pressure ulcers

what is it?

A

Pressure ulcer:

  • Localized injury to the skin and/or underlying tissues.
  • Usually over a bony prominence
  • Result of pressure, or pressure combined with shear/friction.
  • Pressure leads to prolonged ischemia to tissues.
  • Heals by SECONDARY intention
  • Common sites: sacrum, heels, ears, greater trochanter
31
Q

Risk factors for pressure ulcers

A 
Advanced age
Anemia
Contractures
Diabetes
Elevated body temperature
Immobility
Impaired circulation & vascular disease
Incontinence
Mental deterioration
Neurologic disorder
Obesity
Pain
Prolonged surgery
32
Q

Pressure ulcers

injury stages?

A

Pressure injury staging box 16.3 lemone pg 505

Stage I:
Intact skin with nonblanchable redness, localized

Stage 2:
Partial-thickness, exposed dermis, shallow with red-pink granulation. May have an intact or open/ruptured blister.

Stage 3:
Full-thickness tissue loss. Subcutaneous fat, slough may be visible. May include undermining and tunneling.

Stage 4:
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Freq. undermining and tunneling.

Unstageable Ulcer
Base covered with slough or eschar. Can’t evaluate.

33
Q

Risk factor identification: Braden Scale

A

Most widely used risk assessment tool for pressure ulcers

Developed on the basis of risk factors in a nursing home population

Identifies patients at risk and allows preventative measures to be put in place

Total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure development

Cutoff score for onset of pressure ulcer risk for general adult population is 18.

Six subscales are used.

34
Q

Nursing care for pressure ulcer

A

Referrals for wound care and nutrition

Skin inspection as part of physical assessment each shift.

Notify physician of skin breakdown.

Documentation of findings-very specific: location, size, drainage, characteristics, staging of wound, wound care.
Turn patient minimally q 2 hours.

Do not position with pressure on existing wound.

Assess pain/discomfort.
Pressure-relief devices
Incontinent patients must be kept dry.

35
Q

Pressure ulcer labs?

A

Evaluate labs

WBC- inflammation, infection

Proteins, albumin, prealbumin – nutritional status

ESR, C-Reactive protein –inflammation

Coagulation studies –bleeding

Cultures & biopsies

36
Q

Define debridement?

A

Debridement

Removal of nonviable, necrotic tissue

37
Q

Define Induration

A

Induration

An abnormally firm/hard area on the skin.

38
Q

Maceration define

A

Maceration of the skin occurs when it is consistently wet. The skin softens, turns white, and can easily get infected.

39
Q

Sinus tract (tunneling wounds) define

A 
Sinus tract (tunneling wounds) 
A narrow, elongated channel in the body that allows the escape of fluid
40
Q

Slough define

A

Slough

Yellow or white stringy substance attached to wound bed

41
Q

Undermining define

A

Undermining

A chronic skin ulcer having overhanging margins, caused by bacterial infection.

42
Q

Eschar define

A

Eschar

Black or brown necrotic tissue that must be removed for healing.

43
Q

Define Collagen Tissue?

A

connective tissue that in the skin helps in firmness, suppleness and constant renewal of skin cells. Collagen is vital for skin elasticity

44
Q

Define Epithelialization

A

Epithelialization is a process where epithelial cells migrate upwards and repair the wounded area. This process is the most essential part in wound healing and occurs in proliferative phase of wound healing

45
Q

Define granulation tissue

A

Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size

46
Q

Define necrosis

A

Necrosis is the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply

47
Q

What is hydrocolloid (DuoDERM) dressing? what does it do? what stages is it used?

A

Stages: 1, 2, 3, 4
Forms a gel when it come in contact with wound exudate
forms an occlusive barrier over the ulcer while maintaining moisture, preventing infection
Helps prevent friction/shear

48
Q

What is alginate (SilvaSorb/Sorbsan) dressing do? What stages?

A

Stages: 2, 3, 4 with moderate/heavy drainage, infected/uninfected wounds.
Forms gel when contact with exudate.
Apply dry or min draining wounds because of dehydration/delay in healing

49
Q

what is hydrofiber (Aquacel) dressing? what stage?

A

Stages 2, 3, 4 and moderate/heaving exudate.
Used with infection or risk of infection
Combines absorption of hydrofiber with 1.2% silver as antimicrobial

50
Q

what is hydrogel (IntraSite gel) dressing? what stage?

A

Stage 2, 3, 4.
Rehydrates wound bed and decreases pain
Promotes autolytic debridement

51
Q

What is transparent adhesive (OPSITE/Tegaderm) dressing? what stages?

A 
Stages 1, 2, 3
provide moist wound setting
Prevents infection
Promotes reepithelialization
Minimizes friction/shear
52
Q

What is wet to dry dressings?

A

Provides mechanical debridement

53
Q

Wound assessment checklist for documentation

A 
Location
Size
Stage
Drainage
Undermining/tunneling
Character of wound
Dressings
Pressure relieving devices

NUR 141 (48 decks)

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