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Adult Health 2 > Inflammation and Wounds > Flashcards

Inflammation and Wounds Flashcards

1
Q

phases of inflammatory response

A
  • vascular response
  • cellular response
  • exudate
  • healing
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2
Q

cell injury occurs and chemical mediators cause vasodilation and edema

A

vascular response

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3
Q

leukocytes move to site of injury; neutrophils engulf damaged cells; monocytes clean the site of injury; lymphocytes trigger an immune response

A

cellular response

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4
Q

types of fluids present in exudate

A
  • serous: clear
  • serosanguinous: pinkish red
  • fibrinous: stringy material that covers the wound
  • hemorrhagic: blood
  • purulent: pus (WBC, dead cells, and microorganism)
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5
Q

clinical manifestations of local inflammatory response

A
  • erythema
  • swelling
  • pain
  • loss of function
  • hot to touch
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6
Q

clinical manifestations of a systemic inflammatory response

A
  • increased WBC
  • fever
  • fatigue
  • nausea and anorexia
  • tachycardia and tachypnea
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7
Q

nursing management of inflammatory response

A
  • monitor VS especially temp
  • antipyretics for fever greater than 103 (unless pt is uncomfortable)
  • drug therapy
  • RICE (rest, cold/heat, compression, elevation) for soft tissue injury
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8
Q

drug therapy for inflammatory response

A
  • antipyretics
  • NSAIDs
  • corticosteroids
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9
Q

cold vs heat therapy

A
  • cold: at time of injury to decrease swelling and pain

- heat: 24-48 hours after injury to promote healing by increasing circulation to injury

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10
Q

describe compression from RICE

A
  • compression of laceration to prevent bleeding or compression of joint injury to help immobilize and stabilize
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11
Q

what does elevation do from RICE

A

decrease swelling and pain

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12
Q

caused by shear, friction or blunt force resulting in separation of skin layer; common in elderly

A

skin tear

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13
Q

factors that delay wound healing

A
  • nutritional deficiencies
  • inadequate blood supply
  • corticosteroids
  • infection
  • smoking
  • mechanical friction on wound
  • age
  • obesity
  • DM
  • poor general health
  • anemia
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14
Q

complications of wound healing

A
  • adhesions: scar tissue
  • dehiscence: wound edge separate
  • evisceration: wound separates to point where organs protrude from site (medical emergency)
  • infection
  • hemorrhage
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15
Q

how to measure a wound

A
  • use a clock format
  • measure from 12-6 and 9-3 across the wound
  • measure depth (tunneling) using Q-tip
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16
Q

nursing wound management for clean wounds

A

dressing should keep wound surface clean and slightly moist

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17
Q

nursing wound management for contaminated wounds

A
  • must be converted to clean wound by debridement

- wet to dry dressing (debridement is removing old dressing)

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18
Q

nursing wound management for negative pressure wound therapy

A
  • vacuum to remove fluid, exudate, and infectious materials
  • occlusive dressing on top of wound filled with foam
  • done by surgeon or certified wound nurse
19
Q

nursing wound management for hyperbaric oxygen therapy

A
  • most common form is hyperbaric chamber (at wound center)

- high amounts of O2 at high pressure to allow O2 to be delivered to unhealthy tissues

20
Q

general nursing wound management

A
  • nutrition (increase fluid, high protein, carbs, and vitamins)
  • infection prevention and control
  • psychological (worried about scarring)
  • patient teaching about wound care (proper dressing changes, S&S of infection, rest and nutrition)
21
Q

injury to skin and/or underlying tissue as a result of pressure or pressure in combination w/ shear; occurs at bony prominences

A

pressure ulcers

22
Q

most common locations for pressure ulcers

A

sacrum and heels (but can occur anywhere prone to pressure)

23
Q

risk factor for pressure ulcers

A
  • immobility (most common)
  • advanced age
  • dementia
  • anemia
  • contractures
  • DM
  • friction
  • impaired circulation
  • incontinence
  • obesity
  • prolonged surgery
24
Q

prevention of pressure ulcers

A
  • identify those at risk (Braden scale) - high risk if 18 or below
  • turning/positioning (every 2 hours)
  • floating the heals
  • support services (beds, overlays, boots etc.)
  • nutrition
  • incontinence (keep pt dry)
  • lift to shift
  • skin assessments (on admission, every shift, transfer and discharge)
25
Q

factors of the Braden scale

A
  • sensory perception
  • incontinence
  • activity
  • mobility
  • nutrition
  • friction and shear
26
Q

T/F: depends are a good way of dealing with incontinence

A

False; locks in moisture on bony prominences and doesn’t allow airflow -> increased risk of skin breakdown

27
Q

how to assess patient’s with dark skin

A
  • look for change in skin color such as darker than surrounding skin
  • use natural light to assess color
  • assess temperature
  • ask about pain
28
Q

clinical manifestations of stage 1 pressure ulcer

A
  • intact skin w/ non-blanchable redness of a localized area usually over bony prominence
  • can develop and resolve quickly
29
Q

management of stage 1 pressure ulcer

A
  • keep area dry and prevent further injury

- protective ointment

30
Q

clinical manifestations of stage 2 pressure ulcer

A
  • partial thickness loss of dermis
  • shallow open ulcer w/ red or pink wound bed
  • presents as intact ruptured serum-filled blister
  • more painful
31
Q

management of stage 2 pressure ulcer

A
  • preventative measures
  • barrier cream (thick pasty cream that keeps wound protected)
  • numbing ointment
32
Q

clinical manifestations of stage 3 pressure ulcer

A
  • full thickness skin loss

- subcutaneous tissue may be visible but bone, tendon, or muscle not present

33
Q

management of stage 3 pressure ulcer

A
  • keep area moist (wet to dry dressing)
  • preventative measures
  • consult wound care team
34
Q

clinical manifestations of stage 4 pressure ulcer

A
  • full thickness loss that extends to muscle, bone, or supporting structures
  • may include undermining and tunneling
  • takes months to years to heal
35
Q

management of stage 4 pressure ulcer

A
  • wound vac
  • wet to dry dressing
  • consult wound care team
36
Q

clinical manifestations of unstageable pressure ulcer

A
  • full thickness tissue loss in which actual depth of ulcer is completely obscured by slough or eschar
  • needs debridement (either surgical or w/ dressings)
37
Q

necrotic tissue covering wound bed

A

eschar

38
Q

fibrous tissues that wound; more white/tan in color

A

slough

39
Q

clinical manifestations of deep tissue injuries (DTIs)

A
  • purple or maroon localized area of discolored intact skin or blood-filled blister
  • considered pressure injury
  • caused by damage to underlying tissues usually by pressure or shearing
40
Q

acute care of pressure ulcers

A
  • necrotic tissue must be removed
  • clean pressure ulcers w/ noncytotoxic solutions (most facilities have a wound cleansing solution)
  • cover w/ appropriate dressing
  • keep moist
  • nutrition and infection control
  • patient teaching (turning/repositioning, keeping wound clean, S&S of infection)
41
Q

what does a nurse do for pressure injuries

A
  • assess risk and apply care plan
  • assess and document wounds
  • be aware of risks to delay wound healing and minimize risks
  • choose dressings
  • evaluate care
  • provide teaching
42
Q

what does a UAP do for pressure injuries

A
  • empty wound drainage containers and document amount

- report changes in wound appearance or drainage to RN

43
Q

what does a dietician do for pressure injuries

A
  • monitor nutritional status

- establish nutritional interventions

Adult Health 2 (8 decks)

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