Unit 3 - Inflammation, Wound Healing, & SIRS Flashcards
True or False : Inflammation and Infection are the same thing ?
False
___________ is not always present with inflammation ?
Infection
Cardinal signs of local inflammation ?
- Redness
- Warmth
- Pain
- Swelling
- Functional Impairement
Systemic Manifestations of Inflammation ?
- Fever (except in older adults)
- Tachycardia
- Tachypnea
- Malaise
- Leukocytosis (increase in WBC’s)
In terms of Cardinal signs of Local Inflammation, Immunocompromised patients may only present with which sign/symptom ?
Malaise
Cardinal Signs Of Local Inflammation depends on what ?
The Extent and severity of the injury
Infection is defined as what ?
Signs of inflammation PLUS the presence of microorganisms that impair normal wound healing
How log does it take for an infection to occur ?
At least 48 hours
What do you need to do to diagnose an infection ?
- Need to obtain cultures of the site
(wound, urine, sputum, line)
______________ is present with infection, but ___________ is not always present with ___________ ?
inflammation
infection
inflammation
What are the types of inflammation ?
- Acute
- Subacute
- Chronic
Acute inflammation takes how long to heal ?
2 to 3 weeks
____________ inflammation, usually leaves no residual damage ?
Acute inflammation
In Acute inflammation, _____________ are the predominant cell type at the site of inflammation ?
Neutrophils
Subacute inflammation has the same features as ________ inflammation ?
Acute
Subacute inflammation takes how long to heal ?
Longer than 2-3 weeks
___________ inflammation may last for years ?
(weeks, months, years)
Chronic Inflammation
The predominant cell types involved in chronic inflammation are _________ and ____________ ?
Lymphocytes & Macrophages
Immature Neutrophils are known as what ?
BANDS
What are the 2 steps in the inflammatory response ?
- Vascular Response
2. Cellular Response
What happens during the Vascular Response (in the inflammatory response) ?
- Vasodilation and increased capillary permeability cause redness, heat, and swelling
- Fibrin clot traps bacteria
What happens during the Cellular Response of the Inflammatory response ?
- Neutrophils = 1st leukocytes to arrive (w/in 6-12 hrs)
- Phagocytize bacteria. Live 24-48 hours. Dead neutrophils, debris, and digested bacteria become pus
- Monocytes (clean up crew!) arrive w/in 3-7 days
- Lymphocytes (turn into T or B cells)- Arrive in 4-8 days. play a role in Humoral Immunity
_____________ Is the movement of WBC’s towards the site of injury ?
Chemotaxis
What is a Normal WBC count ?
4,000 - 10,000mm3
Leukocytosis is defined as a WBC count of what ?
> 10,000/mm3
- infection, inflammation, leukemia, trauma, or stress
Leukopenia is diende as a WBC count of what ?
< 4,000/mm3
- Overwhelming infection, bone marrow depression, immunosuppression, autoimmune diseases
What are Segs ?
Mature Neutrophil cells
An increase in BANDS indicates what ?
Possible bacterial infection present
________________________ indicates a person’s bone marrow can’t produce enough mature neutrophils to keep up with continued presence of microorganisms. These cells are usually not capable of phagocytosis. ?
Shift to the left
In regards to Fever, _____________ increase the thermostatic set point ?
Prostaglandins
What is a benefit of Fever ?
Includes increased killing of microorganisms !
When managing inflammation, what are ways as nurse that we can monitor and observe for potential infection ?
- Vitals
- Labs (WBC’s & Neutrophils)
- Wound site
- Mental status of elderly patients
RICE stands for what ?
Rest
Ice
Compression
Elevation
Rest = ?
Allow the body to use nutrients and oxygen for the healing process
Ice = ?
24-48 hours post-injury to cause vasoconstriction and decrease the swelling and pain
- Then heat to increase circulation taste and remove debris
Compression = ?
To counter vasodilation and edema
Elevation = ?
Elevate above head to reduce edema and increase venous and lymphatic return
- Toes to Nose !
When managing a fever, what is the most important thing to do ?
** Determine its cause !
Moderate fevers got up to what ?
103*F
What type of fevers usually produce few problems in most patients ?
Moderate Fevers
what temperature are fevers usually treated at ?
101.5*F or greater
At what temperatures do fevers reach the danger zone ?
Above 104*F
What type of symptoms can occur if a person has a temperature above 104*F ?
- Can be damaging to cells
- Cause seizures
- Cause delirium
If _____________________, any temperature elevation needs to be treated and antibiotics begun due to risk of septicemia ?
Immunocompromised
In regards to fevers, sponge baths and cooling blankets can help evaporate heat, but patients still needs to take _______________ to lower the set point. (or antibiotics if infection is suspected/confirmed)!
Antipyretic drugs
When considering drug therapy for individuals with fevers, what do you need to do ?
**Need to five Antipyretics around the clock for fever to prevent temperature swings
Most injuries heal by what ?
Connective tissue repair (scar tissue)
In the Healing Process, _____________ intention healing takes place when wound margins are neatly approximated. As in surgical wounds or a paper cut.
Primary intention
What are examples of Primary intention ?
- Surgical incision
- Paper cut
What are the three phases of Primary Intention ?
- Initial Phase
- Granulation Phase
- Maturation Phase and Scar contraction
The __________ phase of Primary intention is where the edges of the incision are aligned and sutured (or stapled) in place. ?
Initial Phase
The Initial phase of Primary Intention can also be referred to as what ?
The inflammatory phase
In which phase of primary intention, is the area of injury composed of fibrin clots, erythrocytes, neutrophils (dead & Dying) and other debris ?
Initial Phase
___________ are immature connective tissue cells that migrate into the healing site and secrete collagen
Fibroblasts
During which phase of Primary Intention is the wound vascular and pink ?
Granulation phase
During which phase of Primary Intention is the wound friable, at risk for dehiscence and resistant to infection ?
Granulation phase
The Maturation Phase of primary intention may begin when ?
7 days after the injury and can continue for several months or years
- this is why abdominal surgery discharge instructions limit lifting for up to 6 weeks
At which phase of Primary Intention may the scar be more painful than before ?
Maturation phase
In which type intention do wounds occur from trauma, injury and infection ?
Secondary intention
What type of intention results in wounds having large amounts of exudate and wide, irregular wound margins with extensive tissue loss ?
Secondary intention
In which type of intention, may have edges that cannot be approximated (brought together) ?
Secondary intention
What is the major difference between primary intention healing and secondary intention healing ?
The greater defect and the gaping wound edges
In what type of intention does healing and granulation take place from the edges inward and from the bottom of the wound upward until the wound is filled ?
Secondary Intention
In what type of intention is there more granulation tissue, and thus a larger scar ?
Secondary Intention
Tertiary Intention is also known as what ?
Delayed primary intention
Which intention results in delayed suturing of a wound ?
Tertiary Intention
Two layers of granulation tissue are sutured together in which intention ?
Tertiary Intention
What type of intention is it when a contaminated wound is left open and sutured closed after the infection is controlled ?
Tertiary Intention
- It also occurs when a primary wound becomes infected, is opened, allowed to granulate, and then sutured
Tertiary intention usually results in a _______ and ___________________ than primary or secondary intention ?
- Larger
- Deeper scar
What type of Intention DON’T WE WANT ?
Tertiary intention !
Wounds can be classified by what 3 things ?
- Cause (surgical vs nonsurgical /Acute vs chronic)
- Depth of tissue affected
- Color
________ is the least extreme color of wound classification ?
Red
_________ is the most extreme color of wound classification ?
Black
If a wound has two or more colors present, which color do you use to classify the wound ?
The more extreme color
What things cause a delay of healing ?
- Nutritional deficiencies
- Inadequate blood supply
- Corticosteroid drugs
- Infection
- Smoking
_____________ are bands of scar tissue that form between or around organs ?
Adhesions
____________ is a separation and disruption of previously joined wound edges ?
Dehiscence
What steps should be taken if dehiscence occurs to a wound ?
- Cover it with a sterile saline dressing and call the surgeon
____________ is the protrusion of tissue from a wound ?
Evisceration
what steps should be taken if Evisceration occurs to a wound ?
- Cover it with a sterile saline dressing and call the surgeon
__________ formation is an abnormal passage between organs or a hollow organ or skin
Fistula
__________ formation is a great protrusion of scar tissue, thought to be hereditary in dark-skinned persons like African Americans
Keloid formation
______ does not heal all wounds ?
Time !
When should you assess wounds ?
On admission and on a regular basis
Primary intention wounds may be covered with what ?
A dry dressing
Who checks the wound first ?
The Surgeon !
What do you do if the original wound dressing is leaking ?
Leave the original wound dressing on & just re-enforce it with additional dressings, until the surgeon arrives
_________ cleansing antimicrobials should not be used because they can destroy granulation tissue ?
Examples ?
Topical
- Hibiclens (chlorhexidine)
- Hydrogen peroxide
- Dakins solution
What type of wounds require Debridement of nonviable eschar tissue ?
Black wounds
In regards to Black wounds, how is debridement of nonviable eschar tissue done ?
Typically done as a surgery
What is the primary intention of Negative -pressure wound therapy (Wound Vac) ?
Removes drainage and speeds healing !
When using Negative Pressure wound therapy what labs should you monitor for ?
- Serum protein levels
- fluid and electrolyte balance
- Coagulation studies
What Nutrition therapy is necessary for wound healing /
- Diet high in protein
- Carbohydrates
- Vitamins C, B, & A
- Moderate fat
What is a psychological implication of a wound that a patient might have ?`
Fear of scar or disfigurement
What should you do for a patient, if you know the wound care you have to do is going to be painful ?
Pre-medicate
________ __________ are a localized injury to the skin and/or underlying tissue due to pressure with or without shear/friction
Pressure ulcers
______________ is the pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement
Shearing force
_________ is two surfaces rubbing against each other
Friction
Risk Factors for pressure ulcers ?
- Advanced age
- Anemia
- Contractures
- DM
- Elevated body temperature
- Immobility
- Impaired circulation
- Mental deterioration
- Neurologic disorders
- Obesity
- Pain
- Prolonged surgery
- Vascular disease
- Incontinence
- Low diastolic blood pressure (<60mmHg)
Stage _____ pressure ulcer contains intact skin with non-blanchable redness ?
Stage 1 (I)
What stage of pressure ulcers contains:
- Partial-thickness loss of dermis
- Shallow open ulcer with red pink wound bed
- Presents as an intact or ruptures serum-filled blister ?
Stage 2 (II)
What stage of pressure ulcers contain:
- Full thickness skin loss, involving damage or necrosis of subcutaneous tissue that may extend down to, BUT NOT THROUGH underlying fascia ?
Stage 3 (III)
- Presents as a deep crater with possible undermining of adjacent tissue
What stage of pressure ulcer contains:
- Full-thickness loss that can extend to muscle, bone, or supporting structures
- Bone, tendon, or muscle may be visible or palpable
Stage 4 (IV)
With an unstageable wound, What has to be removed before it can be staged ?
Slough or Eschar
And unstageable wound with Eschar needs to be what ?
Surgically debrieded
Complications of pressure ulcers ?
- Recurrence (most common)
- Cellulitis
- Chronic infection
- Osteomyelitis
When should you assess pressure ulcers/risk ?
On admission & at periodic intervals based on care setting and the patients condition
Which risk assessment tool do you use for skin inspection ?
Braden scale
__________ is the best treatment for pressure ulcers ?
Prevention !
What are ways to promote good skin care ?
- Remove excess moisture
- Avoid massage over bony prominences
- Turn every 1 to 2 hours (w/care to avoid shearing)
- Use lift sheets
- Position with pillows or elbow or heal protectors
- Use specialty beds
- Cleanse skin if incontinence occurs
- Keep at 30 degrees or less to prevent shearing force
- EDUCATE PATIENTS ON PREVENTION & TREATMENT AND START AS EARLY AS POSSIBLE !
In regards to pressure ulcers, it is extremely important for diabetics to do what ?
keep blood sugars within normal range
it is recommended to keep wounds _______ ?
moist
Systemic inflammatory response can occur from what ?
- Infection (sepsis)
- ischemia
- infarction
- injury
Ex: burns, crash injuries, surgical procedures, abscess formation, pancreatitis, MI, bacteria, post-cardiac resuscitation, shock
SIRS = ?
uncontrolled inflammation (cytokine excess, widespread endothelial injury, vasodilation, edema)
SIRS can lead to what ?
Multiple Organ Dysfunction Syndrome (MODS)
MODS is defined as what ?
failure of two or more organs
what is the mortality rate for patients with 3 or more organ systems failures ?
70-80%
What is the primary Nursing Consideration for SIRS ?
Preventing infections !
What are steps we can take as a nurse to prevent SIRS infections ?
- Early & frequent ambulation
- Coughing and deep breathing
- Strict asepsis with urinary catheters & IV lines
As a nurse you should do what, to detect signs of MODS ?
Vigilant monitoring !
*Utilize Sepsis Alert Treatment Protocol
_____________ frequently occurs with SIRS ?
Hypoxemia
* Utilize interventions to decrease oxygen demand
sedation, analgesia, rest, mechanical ventilation
Energy expenditure for SIRS is ___ to ___ times the normal ?
1.5 to 2 times the normal
- Need to increase calories!
enteral or parenteral nutrition may be needed
