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NUR 131 > TLO 1.3b Inflammatory > Flashcards

TLO 1.3b Inflammatory Flashcards

1
Q

S/S of inflammation

LOCAL

A 
Local:
pain
erythema
edema
heat
change in function
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2
Q

S/S of inflammation

SYSTEMIC

A 
Systemic:
fever
malaise
N/V
leukocytosis
*fever kills microorganisms, increases phagocytosis
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3
Q

Four types of wound healing

A

Inflammatory Phase
Proliferative Phases
Granulation Tissue
Maturation Phase

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4
Q

Wound healing

INFLAMMATORY PHASE

A

Cleansing phase
Last 1-5 days
Hemostasis: bruising
Inflammation: form scab as protective barrier

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5
Q

Wound healing

PROLIFERATIVE PHASE

A

Granulation phase
Occurs 3-22 days
Cell develop to fill wound causing formation of granulation tissue

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6
Q

Wound healing

GRANULATION TISSUE

A

Beefy red

Bleeds readily and is easily damaged

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7
Q

Wound healing

MATURATION PHASE

A

Epithelialization phase
Final phase
Begins 2nd or 3rd week continues until wound is healed
Collagen in wound bed from proliferative phase broken down to form scar tissue

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8
Q

Factors that inhibit wound healing

A 
Nutritional deficiencies (vit c, protein, zinc)
Impaired O2
Radiation
Medication
Inadequate blood supply
Corticosteroids
Infection
Smoking
Advanced age
Obesity
Diabetes
Anemia
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9
Q

Types of wound healing: 3 types

A

Primary intention
Secondary intention
Tertiary intention

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10
Q

Types of wound healing

PRIMARY INTENTION

A

Little scaring
Wound involves minimal or no tissue loss
Edges are well approximated
Example: clean surgical incision

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11
Q

types of wound healing

SECONDARY INTENTION

A

Wound has extensive tissue loss that prevent edges from approximating
Wound should not be closed (infection)
Heals inner layer to surface with granulation tissue
Heals slower
prone to infection

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12
Q 
types of wound healing
TERTIARY INTENTION (3RD)
A

Delayed primary closure
Initially allowed to heal by 2nd intention
Wound is closed when no s/s of infection
Require strict aseptic technique

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13
Q

Wound drainage: 4

A

Serous: clear, straw color
Purulent: green
Serosanguineous: pink
Sanguineous: red, active bleeding

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14
Q

Wound complications

A 
Hemorrhage
Hematoma
Infection
Dehiscence
Evisceration
Fistula
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15
Q

Erythrocytes (RBC)

  • components
  • values
  • levels
A

Transport O2/CO2
Formed in red bone marrow
women 4-5 million
men 4.5-6 million
Decreased: blood loss, anemia, leukemia, over hydration, pregnant, chronic renal failure
Increased: dehydration, high altitude, cardiovascular disease, polycythemia vera

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16
Q

Plasma

A 
90% water
Dissolved elements:
albumin
globulin
fibrinogen/prothrombin
RBC
WBC
Platelets
17
Q

Leukocytes (WBC)

  • purpose
  • value
  • levels
A

Presence of infection
Diagnose health problem
Adult 4,500-10,000
Leukopenia (low, <4000): lupus, RA, ETOH, viral infection, aplastic/pernicious anemia
Leukocytosis (high, >10,000): acute infection, trauma, tissue necrosis, inflammation, hemorrhage

18
Q

What is WBC w/ differential?

A

Composed of 5 types of WBC’s
Value reported in %
More specific info r/t infection/disease process

19
Q

What are the 5 different types of WBC and values?

A 
Neutrophils: 50-70%
Lymphocytes: 25-35%
Monocytes: 4-6%
Eosinophils: 1-3%
Basophils: 0.4-1%
20
Q

Platelets (thrombocytes)

  • levels
  • value
A

150,000-400,000 normal value
Aids in blood clotting by vasoconstriction and initiate clot formation
Thrombocytosis (increased): infection, acute blood loss, splenectomy
Thrombocytopenia (low): ITP, cancer, liver/kidney disease, lupus

21
Q

Erythrocyte Sedimentation Rate (ESR)

  • levels
  • value
A

Measures rate that RBC settle out of unclotted blood.
Women: 20 mm/hr
Men: 15 mm/hr
Low levels: HR, sickle cell, mono, arthritis
High levels: RA, acute MI, surgery, burns, cancer

22
Q

Wound culture procedure

A

Aseptic technique:

  1. Cleanse/irrigate wound
  2. Collect specimen from granulating tissue
  3. Label and send to lab immediately
    * *Must be done prior to pt receiving antibiotics
23
Q

Wound Cleansing

A 
Use syringe with 19g angiocath
Promotes healthy healing
Use normal saline
Follow doctors orders
PPE
Clean technique
24
Q

Dressing changes- 2 types

A

Dry dressing change: No tough method

Wet to dry moist dressing: used to debride wound, inner gauze moist, loosely pack, apply secondary dressing

25
Q

4 Types of drains

A

Penrose- flexible tubing
Jackson Pratt (JP)- bulb suction
Hemovac- disc shaped
Wound vac

NUR 131 (38 decks)

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