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Fundamentals of Nursing > Inflammation & Wound Healing > Flashcards

Inflammation & Wound Healing Flashcards

1
Q

Localized reaction that produces redness, warmth, swelling, & pai as a result of infection, irritation, or injury

A

Inflammation

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2
Q

Invasion and multiplication of microorganisms such as bacteria, viruses, & parasites that aren’t normally present in the body

A

Infection

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3
Q

Local manifestations of inflammation

A

H- Heat
I - Immobility
P - Pain
E - Edema
R - Redness

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4
Q

Systemic manifestations of inflammation

A
  • Increased WBC w/ shift to the left
  • Fatigue
  • Nausea
  • Anorexia
  • Increased pulse/respiration rate
  • Fever
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5
Q

Two nursing management practices of inflammation

A
  • Fever management
  • RICE: Rest, ice, compression, elevation
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6
Q

Acute Wounds

A

Heal spontaneously w/out complication in a short period of time

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7
Q

Acute wounds are caused by…

A
  • Trauma
  • Surgical Incision
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8
Q

Examples of acute wounds

A
  • Burns, surgical wounds, cuts & scrapes
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9
Q

Signs of acute wound healing

A

Wound edges are clean & intact

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10
Q
  • Natural healing progression is interrupted or stalled
  • Due to infection or underlying disease processes can linger for months/years
A

Chronic Wounds

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11
Q

Chronic wounds are caused by…

A
  • Vascular compromise
  • Chronic inflammation/edema
  • Infection or repetitive insults to tissue
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12
Q

Examples of chronic wounds

A

Ulcers, infected surgical wounds

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13
Q

Signs of healing for chronic wounds

A

Continued exposure to insult impedes wound healing

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14
Q

Deep inflammation of sub-q tissue produced by bacteria

A

Cellulitis

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15
Q

Clinical manifestations of manifestations

A
  • Hot
  • Tender erythematous (red skin) w/ Edema w/ diffuse borders
  • Chills
  • Malaise
  • Fever
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16
Q

Treatment of cellulitis

A
  • Moist heat
  • Elevation & immobilization
  • Systemic antibiotic therapy
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17
Q

Separation or splitting open of layers of a surgical wound

A

Dehiscence

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18
Q

Extrusion of viscera or intestine through a surgical wound

A

Evisceration

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19
Q

Wound involving minimal or no tissue loss & has edges that are well approximated

A

Primary Intention stage of wound healing

20
Q

Example of primary intention of healing

A
  • Surgical incision closed by sutures, stitches, staples, skin glue, or steri strips
  • Clean incisions
  • Hairline scars
21
Q

Involves extensive tissue loss and the wound will be left open to heal by itself and fill in naturally

A

Secondary Intention stage of wound healing

22
Q

Examples of secondary intention wound healing

A

Pressure ulcers

23
Q
  • Initially allowed to heal by second intention
  • When no edema, infection or foreign matter present the edges are brought together and sutured
A

Tertiary Intention wound healing

24
Q

Examples of tertiary wound healing

A

Wound left open to drain & later gets closed

25
-Localized damage to the skin and/or underlying soft tissue - Occurs due to intense and/or prolonged pressure in combo w/ intrinsic & extrinsic factors
Pressure injury
26
Intrinsic factors relating to pressure injuries
- Nutrition - Age - Circulation - Underlying health status
27
Extrinsic factors relating to pressure injuries
- Friction - Shearing - Moisture
28
- Non-blanchable redness usually over bony prominence - May be painful, firm/soft, warm/cool to the touch - Discoloration will remain for more than 30 minutes after pressure removed
Stage 1 pressure injury
29
Describe a stage 1 pressure injury on dark skin
- Blanching may not be visible - Compare changes in color to surrounding tissue, will have purple/bluish tint - Make sure to have excellent lighting when assessing
30
- Partial thickness loss of dermis - Open but shallow w/ red/pink wound bed - No slough - May also be intact or ruptured serum filled blister
Stage 2 pressure injury
31
- Deep crater; full thickness loss w/ damage or necrosis to sub-q tissue - Adipose tissue visible - Extends down to, but not through the fascia - Bone/tendon not visible - Can be EXTREMELY deep in an area with significant adipose tissue
Stage 3 pressure injury
32
- Full thickness w/ extensive destruction, tissue necrosis, or damage to muscle and bone - Exposed bone/tendons - Slough or eschar present - Ebole (edges roll in) undermining & sinus tracts are common
Stage 4 pressure injury
33
What bacteria are always present on your skin?
Staphylococcus & streptococci
34
Dehiscence & evisceration are more common in patients who....
- Overweight - Less muscle tone
35
Pulling a pillow close to you to prevent dehiscence when coughing or sneezing
Splinting
36
Clean incision ---> Early suture ---> Hairline scare
Primary intention wound healing
37
Gaping irregular wound ---> Granulation ---> Epithelium grows over scar
Secondary intention wound healing
38
Wound ---> Increased granulation ---> Late suturing w/ wide scar
Tertiary intention wound healing
39
Factors affecting mobility & activity
- Contractures - Critically ill - Immobility - Hip fracture - Long and/or extensive surgical procedure - Major trauma - Spinal cord injuries
40
Factors affecting sensation
- Long and/or extensive surgical procedure - Spinal cord injuries - Peripheral vascular disorders - Neurological disorders - Diabetes
41
- Full thickness skin loss - Base of wound is obscured by slough or eschar until enough is removed cannot assess the base of the wound, depth, so you cannot stage the wound - Stable eschar is dry, adherent, and intact
Unstageable pressure injury
42
Why do patients not feel pain w/ stage 4 pressure injuries?
The nerve endings have been destroyed
43
- Area of intact skin that is persistently discolored - Can be purpleish, deep red, painful, boggy, or blister - Pain & temperature changes occur before discoloration appears - Injury to underlying soft tissue
Deep tissue pressure injury (DTI)
44
Why are DTIs not as severe as stage 4 pressure injuries?
It is not an open wound so there isn't a risk of infection
45
What do we use for assessing and managing pressure injuries?
Braden Scale
46
What does a low score on the Braden Scale mean?
High risk for pressure injuries

Fundamentals of Nursing (9 decks)

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