inflammatory (class 4)

Question 1

what is the inflammatory response?

Answer 1

sequential reaction to cell injury. neutralizes and dilutes the inflammatory agent. removes necrotic materials. establishes an environment for healing and repair.

Question 2

Acute inflammation?

Answer 2

healing in 2-3 weeks without residual damage, neutrophils are predominant WBC.

Question 3

subacute inflammation?

Answer 3

lasts longer.

Question 4

chronic inflammation?

Answer 4

lasts for weeks, months, or even years with persistent and repeated tissue injury, predominant BC are lympgs and macrophages. Ex. rheumatoid arthritis, osteomyelitis.

Question 5

Local inflammation

Answer 5

pain, erythema, heat, edema, change in function

Question 6

systemic inflammation

Answer 6

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.

Question 7

wound classifications:

Answer 7

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)

Question 8

Regeneration:

Answer 8

replace lost tissue with same type (liver)

Question 9

repair:

Answer 9

replace with connective tissue; various types.

Question 10

primary intention:

Answer 10

type of healing that occurs when wound margins are approximated. ex. surgical inscisions.

Question 11

initial phase

Answer 11

3-5 days, approximation, migration, fibrin meshwork.

Question 12

granulation

Answer 12

5days-3weeks, fibroblasts, surface pink vascular, edges begin to regenerate and migrate.

Question 13

mascarturation & scar contratction

Answer 13

collagen organized/remodeled avascualar scar forms.

Question 14

secondary intention

Answer 14

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.

Question 15

tertiary intention

Answer 15

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.

Question 16

Hemorrhage

Answer 16

hematoma- collection of blood under the tissues

Question 17

infection

Answer 17

signs of infection early withing 2-3 days. surgical wound infection 4-5 days.

Question 18

dehiscence

Answer 18

skin and tissue separated due to poor wound healing

Question 19

evisceration

Answer 19

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.

Question 20

fistula

Answer 20

abnormal passage between 2 organs or between an organ and outside of body. drainage through fistula increases risk of skin breakdown.

Question 21

what delays healing?

Answer 21

inadequate blood supply, obesity, anemia, infection, smoking, friction, advance age, diabetes, corticosteroids, nutritional deficiencies.

Question 22

Vitamin A

Answer 22

aids in process of epithelialization

Question 23

vitamin B

Answer 23

coenzymes for metabolic reactions

Question 24

vtiamin C

Answer 24

promotes formation of collagen fibers and capillary development.

Question 25

Protein (albumin)

Answer 25

provides amino acids for tissue repair

Question 26

carbohydrates

Answer 26

increased metabolic energy

Question 27

fats

Answer 27

aids in synthesis of fatty acids and triglycerides

Question 28

zinc

Answer 28

promotes epithelialization

Question 29

increased fluids

Answer 29

loss from perspiration and exudate

Question 30

MRSA

Answer 30

methicillin resistant staph aureus.

contact precautions, private room, hand washing, instruct on isolation procedures.

Question 31

VRE

Answer 31

vancomycin resistant enterococci. contact precautions private room.

Question 32

RED WOUNDS: clean and pink

Answer 32

deep or superficial

tx: protect granulations, avoid traumatic cleansing.
dressings: transparent film, hydocolloid, hydrogels, gauze & ointment, telfa & ointment.

Question 33

yellow wounds

slough/soft necrotic tissues

Answer 33

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.

Question 34

Black wounds. Eschar. possible purulent drainage

Answer 34

black, grye, brown. Tx: remove necrotic tissue.

dressing: debridement, chemical, surgical, enzymes, mechanical, wound vac.

Question 35

Pressure ulcer

Answer 35

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.

Question 36

pressure ulcer risk factors

Answer 36

advanced age, anemia, contractures, diabetes, elevated body temperature, immobility, impaired circulation & vascular disease, incontinence, mental deterioration, neurologic disorder, obesity, pain, prolonged surgery.

Question 37

stage 1 pressure ulcer

Answer 37

intact skin with nonblanchable redness, localized

Question 38

stage 2:

Answer 38

partial-thickness, exposed dermis, shallow with red-pink granulation. may have an intact or open/ruptured blister

Question 39

stage 3

Answer 39

full-thickness tissue loss subcutaneous fat, slough may be visible. may include undermining and tunneling.

Question 40

stage 4

Answer 40

full-thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present. frequent undermining and tunneling.

Question 41

unstageable

Answer 41

base covered with slough or eschar. cannot evaluate.

Question 42

induration

Answer 42

an abnormally firm/hard area on the skin

Question 43

maceration

Answer 43

occurs when consistently wet. the skin softens, turns white, and can easily get infected.

Question 44

sinus tract (wounds)

Answer 44

a narrow, elongated channel in the body that allows the escape of fluid.