1.3b Inflammatory Flashcards
Inflammatory response definition
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
Role of inflammatory response?
Neutralizes/dilutes inflammatory agent
Removed necrotic materials
Establishes an environment for healing and repair
Inflammation does not always equal infection
INFO
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
Inflammation healing:
Acute?
Subacute?
Chronic?
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
Paradoxically, the inflammatory process?
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.
Inflammatory Response Clinical Manifestations
Local?
Local Pain Erythema, heat Edema Heat Change in function
Inflammatory Response Clinical Manifestations
Systemic?
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
Wound classification
Cause?
Duration?
By cause:
Surgical or nonsurgical
By duration:
acute or chronic (>3 months)
Wound classification
Depth?
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.
Regeneration?
Regeneration: replace lost tissue with same type (liver can rebuild)
Repair?
Repair: replace with connective tissue; various types
Repair: Primary intention, Initial phase?
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
Repair: Primary intention, granulation phase?
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
Repair: Primary intention, maturation and scar contraction phase?
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
Repair: Secondary intention
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
Repair: Tertiary intention
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.
Factors that inhibit healing
Hemorrhage?
Hemorrhage
Hematoma-collection of blood underneath the tissues.
Factors that inhibit healing
Infection?
Infection
Signs of infection early, within 2-3 days.
Surgical wound infection 4-5 days.
Factors that inhibit healing
Dehiscence?
Dehiscence
Skin and tissue separate due to poor wound healing.
Factors that inhibit healing
Evisceration?
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.
Factors that inhibit healing
Fistula?
Fistula
Abnormal passage between 2 organs or between an organ and outside of body.
Drainage through fistula increases risk of skin breakdown.
Factors delaying healing
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
Nutrition and healing
Vit A, B C
Vitamin A
Aids in process of epithelialization.
Vitamin B
Coenzymes for metabolic reactions
Vitamin C
Promotes formation of collagen fibers and capillary development.
Nutrition and healing Protein (albumin) Carbs Fats Zinc Fluids
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
Resistant pathogens
Multidrug resistant pathogens
MRSA : Methicillin resistant Staph aureus
VRE :Vancomycin Resistant Enterococci
Resistant pathogens
isolation
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
Nursing Care of Wounds
On admission
On admission:
Inspect entire body
Record all wounds and appearance & Measure length, width, & depth
Nursing Care of Wounds
Wound care, primary intention healing?
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
Nursing Care of Wounds
Wound care, secondary intention healing?
Secondary Intention healing
- Dressing products: (Lemone pg 505 Table 16-2)
- Clean, prevent & manage infection IRRIGATION
- Manage exudate
- Maintain moist environment
- Protect the wound
Pressure ulcers
what is it?
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
Risk factors for pressure ulcers
Advanced age Anemia Contractures Diabetes Elevated body temperature Immobility Impaired circulation & vascular disease Incontinence Mental deterioration Neurologic disorder Obesity Pain Prolonged surgery
Pressure ulcers
injury stages?
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.
Risk factor identification: Braden Scale
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.
Nursing care for pressure ulcer
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.
Pressure ulcer labs?
Evaluate labs
WBC- inflammation, infection
Proteins, albumin, prealbumin – nutritional status
ESR, C-Reactive protein –inflammation
Coagulation studies –bleeding
Cultures & biopsies
Define debridement?
Debridement
Removal of nonviable, necrotic tissue
Define Induration
Induration
An abnormally firm/hard area on the skin.
Maceration define
Maceration of the skin occurs when it is consistently wet. The skin softens, turns white, and can easily get infected.
Sinus tract (tunneling wounds) define
Sinus tract (tunneling wounds) A narrow, elongated channel in the body that allows the escape of fluid
Slough define
Slough
Yellow or white stringy substance attached to wound bed
Undermining define
Undermining
A chronic skin ulcer having overhanging margins, caused by bacterial infection.
Eschar define
Eschar
Black or brown necrotic tissue that must be removed for healing.
Define Collagen Tissue?
connective tissue that in the skin helps in firmness, suppleness and constant renewal of skin cells. Collagen is vital for skin elasticity
Define Epithelialization
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
Define granulation tissue
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
Define necrosis
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
What is hydrocolloid (DuoDERM) dressing? what does it do? what stages is it used?
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
What is alginate (SilvaSorb/Sorbsan) dressing do? What stages?
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
what is hydrofiber (Aquacel) dressing? what stage?
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
what is hydrogel (IntraSite gel) dressing? what stage?
Stage 2, 3, 4.
Rehydrates wound bed and decreases pain
Promotes autolytic debridement
What is transparent adhesive (OPSITE/Tegaderm) dressing? what stages?
Stages 1, 2, 3 provide moist wound setting Prevents infection Promotes reepithelialization Minimizes friction/shear
What is wet to dry dressings?
Provides mechanical debridement
Wound assessment checklist for documentation
Location Size Stage Drainage Undermining/tunneling Character of wound Dressings Pressure relieving devices
