Medsurg Unit 1 Flashcards
What are the two stages of acute inflammation?
The two stages are vascular and cellular.
What happens during the vascular stage of acute inflammation?
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First, the arterioles and venules near the injury site constrict and then dilate. This increases vascular permeability, which allows fluid to move into the affected tissue. This leads to redness, swelling, heat, pain, and loss of function. ○
Second, blood flow slows and clotting occurs.
What happens during the cellular stage of acute inflammation?
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The cellular stage is initiated by phagocytic leukocytes (white blood cells).
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The leukocytes travel to the site of the injury. First, they adhere to the vessel wall. Then, they squeeze through the vessel wall in a process called emigration.○
Chemotaxis, or chemical signals, guides the leukocytes to the injury site.
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At the injury site, the leukocytes destroy bacteria and other foreign material through phagocytosis.
What is exudate?
Exudate is a fluid composed of plasma and blood cells that accumulates at the site of inflammation. It causes swelling and pain
What is the role of histamine in inflammation?
Histamine is one of the first chemical mediators released when an injury occurs. It causes vasodilation and increases vascular permeability
What are the systemic effects of inflammation?
The most common systemic response to injury is fever. The severity of the fever depends on the size of the injured area.○
Endogenous pyrogens are released from white blood cells. They reset the hypothalamic thermostat, which regulates body temperature, causing fever.
Leukocytosis, an increase in the number of white blood cells, occurs to enhance the body’s ability to fight infection.
Other systemic effects of inflammation include:
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Malaise
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Loss of appetite
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Anorexia
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Sepsis (in severe cases)
What are the three phases of wound healing?
The three phases of wound healing are inflammatory, proliferative, and wound contraction and remodeling.
What happens during the inflammatory phase?
The inflammatory phase begins at the time of injury.
A blood clot forms.
Phagocytic white blood cells travel to the injury site. Neutrophils arrive first, followed by macrophages.
What happens during the proliferative phase?
The proliferative phase involves building new tissue to fill the wound space.
Fibroblasts secrete collagen and other substances that help to form new tissue.
Angiogenesis, the formation of new blood vessels, occurs.
What happens during the wound contraction and remodeling phase?
The wound contraction and remodeling phase begins about three weeks after the injury.
A scar forms. Remodeling can continue for six months or longer
What are some factors that can impair wound healing?
Poor nutrition
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Smoking
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Diabetes
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Poor hygiene
What is the purpose of a surgical drain?
A surgical drain allows fluids to escape from a wound. These fluids could otherwise serve as a culture medium for bacteria.
What are the reasons for applying a dressing to a wound
To provide a proper environment for wound healing
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To absorb drainage
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To splint or immobilize the wound
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To protect the wound and new epithelial tissue from mechanical injury
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To protect the wound from bacterial contamination and from soiling
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To promote hemostasis
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To provide mental and physical comfort for the patient
What is the role of the nurse in caring for surgical drains?
The nurse monitors the amount and type of drainage from the drain.
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The nurse also assesses the drain site for signs of infection, such as redness, swelling, or pain.
What are the steps involved in changing a dressing?
he nurse performs hand hygiene before and after the dressing change.
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Most dressing changes following surgery are sterile.
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The tape is removed by pulling it parallel to the skin in the direction of hair growth. Alcohol wipes can help to remove adhesive.
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The soiled dressing is removed and placed in a biohazard waste container.
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The nurse changes gloves.
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The wound is cleaned with sterile saline solution or another prescribed solution.
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A new dressing is applied.
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The nurse educates the patient on how to care for the incision.
