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J2 - Med Surg > Unit 3 - Inflammation, Wound Healing, & SIRS > Flashcards

Unit 3 - Inflammation, Wound Healing, & SIRS Flashcards

1
Q

True or False : Inflammation and Infection are the same thing ?

A

False

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2
Q

___________ is not always present with inflammation ?

A

Infection

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3
Q

Cardinal signs of local inflammation ?

A
  • Redness
  • Warmth
  • Pain
  • Swelling
  • Functional Impairement
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4
Q

Systemic Manifestations of Inflammation ?

A
  • Fever (except in older adults)
  • Tachycardia
  • Tachypnea
  • Malaise
  • Leukocytosis (increase in WBC’s)
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5
Q

In terms of Cardinal signs of Local Inflammation, Immunocompromised patients may only present with which sign/symptom ?

A

Malaise

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6
Q

Cardinal Signs Of Local Inflammation depends on what ?

A

The Extent and severity of the injury

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7
Q

Infection is defined as what ?

A

Signs of inflammation PLUS the presence of microorganisms that impair normal wound healing

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8
Q

How log does it take for an infection to occur ?

A

At least 48 hours

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9
Q

What do you need to do to diagnose an infection ?

A
  • Need to obtain cultures of the site

(wound, urine, sputum, line)

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10
Q

______________ is present with infection, but ___________ is not always present with ___________ ?

A

inflammation
infection
inflammation

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11
Q

What are the types of inflammation ?

A
  • Acute
  • Subacute
  • Chronic
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12
Q

Acute inflammation takes how long to heal ?

A

2 to 3 weeks

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13
Q

____________ inflammation, usually leaves no residual damage ?

A

Acute inflammation

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14
Q

In Acute inflammation, _____________ are the predominant cell type at the site of inflammation ?

A

Neutrophils

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15
Q

Subacute inflammation has the same features as ________ inflammation ?

A

Acute

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16
Q

Subacute inflammation takes how long to heal ?

A

Longer than 2-3 weeks

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17
Q

___________ inflammation may last for years ?

(weeks, months, years)

A

Chronic Inflammation

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18
Q

The predominant cell types involved in chronic inflammation are _________ and ____________ ?

A

Lymphocytes & Macrophages

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19
Q

Immature Neutrophils are known as what ?

A

BANDS

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20
Q

What are the 2 steps in the inflammatory response ?

A
  1. Vascular Response

2. Cellular Response

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21
Q

What happens during the Vascular Response (in the inflammatory response) ?

A
  • Vasodilation and increased capillary permeability cause redness, heat, and swelling
  • Fibrin clot traps bacteria
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22
Q

What happens during the Cellular Response of the Inflammatory response ?

A
  • 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
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23
Q

_____________ Is the movement of WBC’s towards the site of injury ?

A

Chemotaxis

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24
Q

What is a Normal WBC count ?

A

4,000 - 10,000mm3

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25
Q

Leukocytosis is defined as a WBC count of what ?

A

> 10,000/mm3

  • infection, inflammation, leukemia, trauma, or stress
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26
Q

Leukopenia is diende as a WBC count of what ?

A

< 4,000/mm3

  • Overwhelming infection, bone marrow depression, immunosuppression, autoimmune diseases
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27
Q

What are Segs ?

A

Mature Neutrophil cells

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28
Q

An increase in BANDS indicates what ?

A

Possible bacterial infection present

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29
Q

________________________ 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. ?

A

Shift to the left

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30
Q

In regards to Fever, _____________ increase the thermostatic set point ?

A

Prostaglandins

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31
Q

What is a benefit of Fever ?

A

Includes increased killing of microorganisms !

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32
Q

When managing inflammation, what are ways as nurse that we can monitor and observe for potential infection ?

A
  • Vitals
  • Labs (WBC’s & Neutrophils)
  • Wound site
  • Mental status of elderly patients
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33
Q

RICE stands for what ?

A

Rest
Ice
Compression
Elevation

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34
Q

Rest = ?

A

Allow the body to use nutrients and oxygen for the healing process

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35
Q

Ice = ?

A

24-48 hours post-injury to cause vasoconstriction and decrease the swelling and pain
- Then heat to increase circulation taste and remove debris

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36
Q

Compression = ?

A

To counter vasodilation and edema

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37
Q

Elevation = ?

A

Elevate above head to reduce edema and increase venous and lymphatic return

  • Toes to Nose !
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38
Q

When managing a fever, what is the most important thing to do ?

A

** Determine its cause !

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39
Q

Moderate fevers got up to what ?

A

103*F

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40
Q

What type of fevers usually produce few problems in most patients ?

A

Moderate Fevers

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41
Q

what temperature are fevers usually treated at ?

A

101.5*F or greater

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42
Q

At what temperatures do fevers reach the danger zone ?

A

Above 104*F

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43
Q

What type of symptoms can occur if a person has a temperature above 104*F ?

A
  • Can be damaging to cells
  • Cause seizures
  • Cause delirium
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44
Q

If _____________________, any temperature elevation needs to be treated and antibiotics begun due to risk of septicemia ?

A

Immunocompromised

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45
Q

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)!

A

Antipyretic drugs

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46
Q

When considering drug therapy for individuals with fevers, what do you need to do ?

A

**Need to five Antipyretics around the clock for fever to prevent temperature swings

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47
Q

Most injuries heal by what ?

A

Connective tissue repair (scar tissue)

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48
Q

In the Healing Process, _____________ intention healing takes place when wound margins are neatly approximated. As in surgical wounds or a paper cut.

A

Primary intention

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49
Q

What are examples of Primary intention ?

A
  • Surgical incision

- Paper cut

50
Q

What are the three phases of Primary Intention ?

A
  • Initial Phase
  • Granulation Phase
  • Maturation Phase and Scar contraction
51
Q

The __________ phase of Primary intention is where the edges of the incision are aligned and sutured (or stapled) in place. ?

A

Initial Phase

52
Q

The Initial phase of Primary Intention can also be referred to as what ?

A

The inflammatory phase

53
Q

In which phase of primary intention, is the area of injury composed of fibrin clots, erythrocytes, neutrophils (dead & Dying) and other debris ?

A

Initial Phase

54
Q

___________ are immature connective tissue cells that migrate into the healing site and secrete collagen

A

Fibroblasts

55
Q

During which phase of Primary Intention is the wound vascular and pink ?

A

Granulation phase

56
Q

During which phase of Primary Intention is the wound friable, at risk for dehiscence and resistant to infection ?

A

Granulation phase

57
Q

The Maturation Phase of primary intention may begin when ?

A

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
58
Q

At which phase of Primary Intention may the scar be more painful than before ?

A

Maturation phase

59
Q

In which type intention do wounds occur from trauma, injury and infection ?

A

Secondary intention

60
Q

What type of intention results in wounds having large amounts of exudate and wide, irregular wound margins with extensive tissue loss ?

A

Secondary intention

61
Q

In which type of intention, may have edges that cannot be approximated (brought together) ?

A

Secondary intention

62
Q

What is the major difference between primary intention healing and secondary intention healing ?

A

The greater defect and the gaping wound edges

63
Q

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 ?

A

Secondary Intention

64
Q

In what type of intention is there more granulation tissue, and thus a larger scar ?

A

Secondary Intention

65
Q

Tertiary Intention is also known as what ?

A

Delayed primary intention

66
Q

Which intention results in delayed suturing of a wound ?

A

Tertiary Intention

67
Q

Two layers of granulation tissue are sutured together in which intention ?

A

Tertiary Intention

68
Q

What type of intention is it when a contaminated wound is left open and sutured closed after the infection is controlled ?

A

Tertiary Intention

  • It also occurs when a primary wound becomes infected, is opened, allowed to granulate, and then sutured
69
Q

Tertiary intention usually results in a _______ and ___________________ than primary or secondary intention ?

A
  • Larger

- Deeper scar

70
Q

What type of Intention DON’T WE WANT ?

A

Tertiary intention !

71
Q

Wounds can be classified by what 3 things ?

A
  • Cause (surgical vs nonsurgical /Acute vs chronic)
  • Depth of tissue affected
  • Color
72
Q

________ is the least extreme color of wound classification ?

A

Red

73
Q

_________ is the most extreme color of wound classification ?

A

Black

74
Q

If a wound has two or more colors present, which color do you use to classify the wound ?

A

The more extreme color

75
Q

What things cause a delay of healing ?

A
  • Nutritional deficiencies
  • Inadequate blood supply
  • Corticosteroid drugs
  • Infection
  • Smoking
76
Q

_____________ are bands of scar tissue that form between or around organs ?

A

Adhesions

77
Q

____________ is a separation and disruption of previously joined wound edges ?

A

Dehiscence

78
Q

What steps should be taken if dehiscence occurs to a wound ?

A
  • Cover it with a sterile saline dressing and call the surgeon
79
Q

____________ is the protrusion of tissue from a wound ?

A

Evisceration

80
Q

what steps should be taken if Evisceration occurs to a wound ?

A
  • Cover it with a sterile saline dressing and call the surgeon
81
Q

__________ formation is an abnormal passage between organs or a hollow organ or skin

A

Fistula

82
Q

__________ formation is a great protrusion of scar tissue, thought to be hereditary in dark-skinned persons like African Americans

A

Keloid formation

83
Q

______ does not heal all wounds ?

A

Time !

84
Q

When should you assess wounds ?

A

On admission and on a regular basis

85
Q

Primary intention wounds may be covered with what ?

A

A dry dressing

86
Q

Who checks the wound first ?

A

The Surgeon !

87
Q

What do you do if the original wound dressing is leaking ?

A

Leave the original wound dressing on & just re-enforce it with additional dressings, until the surgeon arrives

88
Q

_________ cleansing antimicrobials should not be used because they can destroy granulation tissue ?

Examples ?

A

Topical

  • Hibiclens (chlorhexidine)
  • Hydrogen peroxide
  • Dakins solution
89
Q

What type of wounds require Debridement of nonviable eschar tissue ?

A

Black wounds

90
Q

In regards to Black wounds, how is debridement of nonviable eschar tissue done ?

A

Typically done as a surgery

91
Q

What is the primary intention of Negative -pressure wound therapy (Wound Vac) ?

A

Removes drainage and speeds healing !

92
Q

When using Negative Pressure wound therapy what labs should you monitor for ?

A
  • Serum protein levels
  • fluid and electrolyte balance
  • Coagulation studies
93
Q

What Nutrition therapy is necessary for wound healing /

A
  • Diet high in protein
  • Carbohydrates
  • Vitamins C, B, & A
  • Moderate fat
94
Q

What is a psychological implication of a wound that a patient might have ?`

A

Fear of scar or disfigurement

95
Q

What should you do for a patient, if you know the wound care you have to do is going to be painful ?

A

Pre-medicate

96
Q

________ __________ are a localized injury to the skin and/or underlying tissue due to pressure with or without shear/friction

A

Pressure ulcers

97
Q

______________ is the pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement

A

Shearing force

98
Q

_________ is two surfaces rubbing against each other

A

Friction

99
Q

Risk Factors for pressure ulcers ?

A
  • 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)
100
Q

Stage _____ pressure ulcer contains intact skin with non-blanchable redness ?

A

Stage 1 (I)

101
Q

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 ?
A

Stage 2 (II)

102
Q

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 ?

A

Stage 3 (III)

  • Presents as a deep crater with possible undermining of adjacent tissue
103
Q

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
A

Stage 4 (IV)

104
Q

With an unstageable wound, What has to be removed before it can be staged ?

A

Slough or Eschar

105
Q

And unstageable wound with Eschar needs to be what ?

A

Surgically debrieded

106
Q

Complications of pressure ulcers ?

A
  • Recurrence (most common)
  • Cellulitis
  • Chronic infection
  • Osteomyelitis
107
Q

When should you assess pressure ulcers/risk ?

A

On admission & at periodic intervals based on care setting and the patients condition

108
Q

Which risk assessment tool do you use for skin inspection ?

A

Braden scale

109
Q

__________ is the best treatment for pressure ulcers ?

A

Prevention !

110
Q

What are ways to promote good skin care ?

A
  • 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 !
111
Q

In regards to pressure ulcers, it is extremely important for diabetics to do what ?

A

keep blood sugars within normal range

112
Q

it is recommended to keep wounds _______ ?

A

moist

113
Q

Systemic inflammatory response can occur from what ?

A
  • Infection (sepsis)
  • ischemia
  • infarction
  • injury

Ex: burns, crash injuries, surgical procedures, abscess formation, pancreatitis, MI, bacteria, post-cardiac resuscitation, shock

114
Q

SIRS = ?

A 
uncontrolled inflammation
(cytokine excess, widespread endothelial injury, vasodilation, edema)
115
Q

SIRS can lead to what ?

A

Multiple Organ Dysfunction Syndrome (MODS)

116
Q

MODS is defined as what ?

A

failure of two or more organs

117
Q

what is the mortality rate for patients with 3 or more organ systems failures ?

A

70-80%

118
Q

What is the primary Nursing Consideration for SIRS ?

A

Preventing infections !

119
Q

What are steps we can take as a nurse to prevent SIRS infections ?

A
  • Early & frequent ambulation
  • Coughing and deep breathing
  • Strict asepsis with urinary catheters & IV lines
120
Q

As a nurse you should do what, to detect signs of MODS ?

A

Vigilant monitoring !

*Utilize Sepsis Alert Treatment Protocol

121
Q

_____________ frequently occurs with SIRS ?

A

Hypoxemia

* Utilize interventions to decrease oxygen demand
sedation, analgesia, rest, mechanical ventilation

122
Q

Energy expenditure for SIRS is ___ to ___ times the normal ?

A

1.5 to 2 times the normal

- Need to increase calories!
enteral or parenteral nutrition may be needed

J2 - Med Surg (16 decks)

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