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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
factors of the Braden scale
- sensory perception - incontinence - activity - mobility - nutrition - friction and shear
26
T/F: depends are a good way of dealing with incontinence
False; locks in moisture on bony prominences and doesn't allow airflow -> increased risk of skin breakdown
27
how to assess patient's with dark skin
- look for change in skin color such as darker than surrounding skin - use natural light to assess color - assess temperature - ask about pain
28
clinical manifestations of stage 1 pressure ulcer
- intact skin w/ non-blanchable redness of a localized area usually over bony prominence - can develop and resolve quickly
29
management of stage 1 pressure ulcer
- keep area dry and prevent further injury | - protective ointment
30
clinical manifestations of stage 2 pressure ulcer
- partial thickness loss of dermis - shallow open ulcer w/ red or pink wound bed - presents as intact ruptured serum-filled blister - more painful
31
management of stage 2 pressure ulcer
- preventative measures - barrier cream (thick pasty cream that keeps wound protected) - numbing ointment
32
clinical manifestations of stage 3 pressure ulcer
- full thickness skin loss | - subcutaneous tissue may be visible but bone, tendon, or muscle not present
33
management of stage 3 pressure ulcer
- keep area moist (wet to dry dressing) - preventative measures - consult wound care team
34
clinical manifestations of stage 4 pressure ulcer
- full thickness loss that extends to muscle, bone, or supporting structures - may include undermining and tunneling - takes months to years to heal
35
management of stage 4 pressure ulcer
- wound vac - wet to dry dressing - consult wound care team
36
clinical manifestations of unstageable pressure ulcer
- 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
necrotic tissue covering wound bed
eschar
38
fibrous tissues that wound; more white/tan in color
slough
39
clinical manifestations of deep tissue injuries (DTIs)
- 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
acute care of pressure ulcers
- 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
what does a nurse do for pressure injuries
- 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
what does a UAP do for pressure injuries
- empty wound drainage containers and document amount | - report changes in wound appearance or drainage to RN
43
what does a dietician do for pressure injuries
- monitor nutritional status | - establish nutritional interventions

Adult Health 2 (8 decks)

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