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Fundamentals of Nursing > Inflammation & Wound Healing > Flashcards

Inflammation & Wound Healing Flashcards

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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
Q

-Localized damage to the skin and/or underlying soft tissue

  • Occurs due to intense and/or prolonged pressure in combo w/ intrinsic & extrinsic factors
A

Pressure injury

26
Q

Intrinsic factors relating to pressure injuries

A
  • Nutrition
  • Age
  • Circulation
  • Underlying health status
27
Q

Extrinsic factors relating to pressure injuries

A
  • Friction
  • Shearing
  • Moisture
28
Q
  • 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
A

Stage 1 pressure injury

29
Q

Describe a stage 1 pressure injury on dark skin

A
  • 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
Q
  • Partial thickness loss of dermis
  • Open but shallow w/ red/pink wound bed
  • No slough
  • May also be intact or ruptured serum filled blister
A

Stage 2 pressure injury

31
Q
  • 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
A

Stage 3 pressure injury

32
Q
  • 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
A

Stage 4 pressure injury

33
Q

What bacteria are always present on your skin?

A

Staphylococcus & streptococci

34
Q

Dehiscence & evisceration are more common in patients who….

A
  • Overweight
  • Less muscle tone
35
Q

Pulling a pillow close to you to prevent dehiscence when coughing or sneezing

A

Splinting

36
Q

Clean incision —> Early suture —> Hairline scare

A

Primary intention wound healing

37
Q

Gaping irregular wound —> Granulation —> Epithelium grows over scar

A

Secondary intention wound healing

38
Q

Wound —> Increased granulation —> Late suturing w/ wide scar

A

Tertiary intention wound healing

39
Q

Factors affecting mobility & activity

A
  • Contractures
  • Critically ill
  • Immobility
  • Hip fracture
  • Long and/or extensive surgical procedure
  • Major trauma
  • Spinal cord injuries
40
Q

Factors affecting sensation

A
  • Long and/or extensive surgical procedure
  • Spinal cord injuries
  • Peripheral vascular disorders
  • Neurological disorders
  • Diabetes
41
Q
  • 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
A

Unstageable pressure injury

42
Q

Why do patients not feel pain w/ stage 4 pressure injuries?

A

The nerve endings have been destroyed

43
Q
  • 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
A

Deep tissue pressure injury (DTI)

44
Q

Why are DTIs not as severe as stage 4 pressure injuries?

A

It is not an open wound so there isn’t a risk of infection

45
Q

What do we use for assessing and managing pressure injuries?

A

Braden Scale

46
Q

What does a low score on the Braden Scale mean?

A

High risk for pressure injuries

Fundamentals of Nursing (9 decks)

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