inflammatory (class 4) Flashcards
what is the inflammatory response?
sequential reaction to cell injury. neutralizes and dilutes the inflammatory agent. removes necrotic materials. establishes an environment for healing and repair.
Acute inflammation?
healing in 2-3 weeks without residual damage, neutrophils are predominant WBC.
subacute inflammation?
lasts longer.
chronic inflammation?
lasts for weeks, months, or even years with persistent and repeated tissue injury, predominant BC are lympgs and macrophages. Ex. rheumatoid arthritis, osteomyelitis.
Local inflammation
pain, erythema, heat, edema, change in function
systemic inflammation
elevated T,P,R. increased WBC with shift to left, vascular response inflammatory mediators (histamine, prostaglandins, leukotriene) cause vasodilation & increase capillary permeability. cytokines cause fever.
wound classifications:
by cause: surgical or nonsurgical.
by duration: acute or chronic (>3months)
By depth of tissue affected: superficial (involves epidermis) partial thickness (wound extends into dermis) full thickness (involves subcutaneous tissue and may extend to fascia, muscle, tendon, or bone)
Regeneration:
replace lost tissue with same type (liver)
repair:
replace with connective tissue; various types.
primary intention:
type of healing that occurs when wound margins are approximated. ex. surgical inscisions.
initial phase
3-5 days, approximation, migration, fibrin meshwork.
granulation
5days-3weeks, fibroblasts, surface pink vascular, edges begin to regenerate and migrate.
mascarturation & scar contratction
collagen organized/remodeled avascualar scar forms.
secondary intention
type of healing for wounds that have large amounts of exudate, wide irregular margins and extensive tissue loss and edges cannot 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 life primary intention but more granulation and tissue scarring.
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.
Hemorrhage
hematoma- collection of blood under the tissues
infection
signs of infection early withing 2-3 days. surgical wound infection 4-5 days.
dehiscence
skin and tissue separated due to poor wound healing
evisceration
total separation of wound layers with protrusion of visceral organs through wound opening. emergency situation. nurse to place sterile towel soaked in NS over eviscerated area, NPO.
fistula
abnormal passage between 2 organs or between an organ and outside of body. drainage through fistula increases risk of skin breakdown.
what delays healing?
inadequate blood supply, obesity, anemia, infection, smoking, friction, advance age, diabetes, corticosteroids, nutritional deficiencies.
Vitamin A
aids in process of epithelialization
vitamin B
coenzymes for metabolic reactions
vtiamin C
promotes formation of collagen fibers and capillary development.
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
MRSA
methicillin resistant staph aureus.
contact precautions, private room, hand washing, instruct on isolation procedures.
VRE
vancomycin resistant enterococci. contact precautions private room.
RED WOUNDS: clean and pink
deep or superficial
tx: protect granulations, avoid traumatic cleansing.
dressings: transparent film, hydocolloid, hydrogels, gauze & ointment, telfa & ointment.
yellow wounds
slough/soft necrotic tissues
bacteria love necrotic tissues. tx: cleansing to remove nonviable tissues & absorb excessive drainage.
Dressing care: absorptive dressing, hydrocolloid, hydrogel with gauze, irrigations, moist gauze, hydrotherapy, negative pressure vacs.
Black wounds. Eschar. possible purulent drainage
black, grye, brown. Tx: remove necrotic tissue.
dressing: debridement, chemical, surgical, enzymes, mechanical, wound vac.
Pressure ulcer
localized injury to 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, ear, greater trochanter.
pressure ulcer risk factors
advanced age, anemia, contractures, diabetes, elevated body temperature, immobility, impaired circulation & vascular disease, incontinence, mental deterioration, neurologic disorder, obesity, pain, prolonged surgery.
stage 1 pressure ulcer
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. frequent undermining and tunneling.
unstageable
base covered with slough or eschar. cannot evaluate.
induration
an abnormally firm/hard area on the skin
maceration
occurs when consistently wet. the skin softens, turns white, and can easily get infected.
sinus tract (wounds)
a narrow, elongated channel in the body that allows the escape of fluid.
