wound and inflammation

Question 1

Why does the health care provider not order an antibiotic for the patient with a viral infection?

Answer 1

Antibiotics are not effective in treating viral infections. Antibiotics have a specific mechanism of action that will not work on viruses.

Question 2

How does knowing the portal of exit help the RN determine what PPE’s is needed?

Answer 2

Portal of Exit is the path by which the causative agent gets out of the reservoir. Ex. body fluids, bacteria, MRSA, can all live and grow on the skin and may have multiple paths of exit from the body. Knowing the infected organism and it;s portal of entry to cause the risk for infection (i.e. mouth, nose, ears, eyes, skin abrasions, cuts) will assist the RN to know what her/his risk for “catching” the infection and will know how best to be protected while caring for the patient. Ex, Goggles, Gloves, Gowns, Face masks

Question 3

Sanguineous drainage

Answer 3

Large amounts of RBC’s; damage to capillaries severe enough to allow escape of RBC’s from plasma. Found in open wounds.

Question 4

serosanguineous drainage

Answer 4

Composed of RBC’s and serous fluid. Fluid is semi-clear pink and may have red streaks. Found during midpoint in healing. (Surgery/ Tissue healing)

Question 5

Serous Drainage

Answer 5

Consists of WBC’s (serum), watery, has few cells (Blisters) Seen in early stages of inflammation; the injury is mild.

Question 6

Purulent drainage

Answer 6

Thicker than serous; pus-like. Consists of Leukocytes, liquified dead tissue debris. Consists of WBC’s; dead or alive microorganisms. Vary in color: Blue, green, yellow.

Question 7

Is it possible for a patient to have a nursing diagnoses of Impaired Skin Integrity and a Risk for Impaired Skin Integrity?

Answer 7

Yes, because there may already be proof/signs of skin breakdown; i.e. pressure ulcers, shear/friction of skin, but then due to altercations like limited activity, poor nutrition, incontinence, and other related problems, there can be a risk for other skin breakdowns to occur elsewhere on the body.

Question 8

Define/Describe: Partial thickness

Answer 8

, loss of dermis. Shallow open ulcer with red/pink wound bed, w/o slough. Intact or open/ruptured serum filled blister.

Question 9

Hydrocolloids Dressing

Answer 9

Waterproof adhesive wafers; worn up to 7 days. Consist of two layers: 1- absorbs exudates; forms a hydrated gel; 2- provides an occlusive seal.
Purpose: To absorb exudate; produce a warm environment that facillitates healing but does not cause maceration of surrounding skin.

Question 10

Collagen

Answer 10

Description: Gels, pastes, powders, granules, sheets, sponges, all derived from animal sources. Ex. cows and pigs
Purpose: Assists with stop in bleeding, helps recruit cells into the woundbed and stimulates proliferation to facilitate healing.

Question 11

List factors responsible for secondary immunodeficiencies in patients

Answer 11

Drug- induced Immunodeficiency: Corticosteroids, Chemotherapy
Age- Infant/ Older Adults
Malnutrition
Therapies
Disease/ Disorders
Stress

Question 12

Which primary prevention measures may decrease an individual’s susceptibility to infection?

Answer 12

Hygiene- Hand-washing, bathing, oral care
Nutrition: Balanced Diet
Fluid: Ample intake of fluids helps to remove possible infection causing microorganisms from the body
Sleep: Adequate sleep patterns
Stress: Stress reduced lifestyles
Immunizations

Question 13

) What are the phases in primary intention healing?

Answer 13

• Initial Phase: Lasts 3-5 days, approximation of incision edges, migration of epithelial cells, clots serve as mesh work for new capillary growth.
• Granulation Phase: 5 days-4 weeks, Migration of fibroblasts, secretion of collagen, fragility of wound.
• Scar Contraction Phase: 7 days- several months: remodeling of collagen, strengthening of scar.

Question 14

Describe how each sub scale area may be a possible etiology for the nursing diagnosis Risk for Impaired Skin Integrity:

Answer 14

• Sensory Perception: inability to sense pressure will inhibit pt from sensing the need for re-positioning, eventually leading to breakdown.
• Moisture: prolonged exposure to moisture results in softening of the skin (maceration).
• Activity: Activity improves blood flow, decreased activity means prolonged periods of rest in the same position with decreased blood flow to skin.
• Mobility: Like activity, mobility improves blood flow. If the patient is immobile, they are likely to remain in one position for an extended period of time.
• Nutrition: inadequate fluid and nutrient intake decreases the integrity of the skin.
• Friction/Shear: these actions can cause separation of and damage to of skin cells/tissue.

Question 15

Identify the purposes for occlusive dressings. When are they used?

Answer 15

Occlusive dressings seal the wound completely to prevent infection from outside and prevent inner moisture from escaping through dressing. Used for various stage II-IV pressure ulcers, some skin tears and incisions, and in areas where bacterial content it abundant.

Question 16

STAVE IV

Answer 16

Define: Full thickness lossexposed bone muscle or tendonslough or eschar may be present as well as undermining.
Type of Dressings/purpose: Hydrocolloids-absorb exudate, provide moist environment without maceration, protect against bacteria, foreign debris, urine, and feces, prevent shearing. Hydrogels-Liquefy necrotic tissues, rehydrate wound bed, fill in dead space.

Question 17

List two primary preventive care activities to maintain a “healthy” immune status.

Answer 17

• Balance Diet
• Sleep 8 hours/night.
• Exercise 3-5 x’s/week

Question 18

Frequent and thorough handwashing is essential in infection control. List the steps of the recommended technique with rationale.

Answer 18

1) Wet hands with warm water. (Warm water works with soap to kill bacteria)
2) Apply anti-bacterial/microbial soap. (Soaps contain chemicals that assist to decrease pathogen count)
3) Lather soap and rub hands together. (Friction acts to remove bacteria from skin. Attention to nails and between fingers focuses on common areas for bacterial growth).
4) Rinse with warm water. (Rinsing washes away the soap and bacteria).
5) Dry hands, turn off faucet with paper towel. (Drying hands promotes healthy skin, turning off faucet with paper towel decreases risk of recontamination)

Question 19

Transparent Film Dressing

Answer 19

Description: Adhesive plastic, semi permeable, non absorbent dressings allow exchange of oxygen between the atmosphere and wound bed. They are impermeable to bacteria and water.
Purpose: To provide protection against contamination and friction; to maintain a clean moist surface that facilitate cellular migration; to provide insulation by preventing fluid evaporation and to facilitate wound assessment.

Question 20

If a drain is present, why is the drain site dressed separately?

Answer 20

The dressing absorbs the drainage and helps prevent it from excoriating the skin

Question 21

Why does management of a secondary intention wound depend on the etiology and type of tissue in the wound?

Answer 21

. Wounds that are extensive and involves considerable tissue loss and edges can not or should not be approximated heals by 2nd intention. Pressure ulcers is an example. Healing takes longer, scarring is greater, and susceptibility to infection is greater.

Question 22

Stage I

Answer 22

(define/ describe) nonblanchable erythema signaling potential ulceration, erythema that does not go away with in minutes of pressure relief. (type of dressing) transparent film. (purpose) provide prtection against contamination and friction,

Question 23

How does healing of an open wound differ from a closed wound?

Answer 23

Both wounds go through the healing process of:
Inflammation (initial) phase (3-5 days) Migration of epithelial cells; clot serving as meshwork for starting capillary growth
Granulation phase (5 days to 4 weeks) Migration of fibroblast; secretion of collagen; abundance of capillary buds; fragility of wound
Maturation phase (7days to several months) Remolding of collagen; strengthening of scar
closed wound occurs when the tissue surfaces have been closed and there is minimal or not tissue loss; it is characterized by the formation of minimal granululation tissue and scarring
Closed wounds is where tissue surfaces are approximated (closed) which reduces exposure to infectious agents
Open wounds the repair time is longer, (greater tissue loss), the scarring is greater and the susceptibility to infection is greater.

Question 24

What is the purpose of a closed suction drain? How does it influence healing?

Answer 24

Closed wound drainage system consists of a drain connected to either an electric suction or portable drainage suction (eg. Hemovac or Jackson-Pratt). The closed system reduces the potential entry of microorganisms into the wound through the drain. The drainage tubes are sutured into place and connected to a reservoir that maintains constant low suction. It influences healing by facilitating removal of fluid and exudates that might otherwise interfere with the formation of granulation tissue.

Question 25

Alginates

Answer 25

Description Nonwoven, non adhesive pads & ribbons composed of natural polysaccharide fibers or xerogel derived from seaweed. On contact with exudates, form a moist gel. Easy to use over irregular-shaped wounds. Indicated for wounds with moderate to heavy exudates (eg. pressure ulcers, infected wounds). Generally require a secondary dressing. Purpose: To provide moist wound surface by interacting with exudates to form a gelatinous mass; to absorb exudates; to eliminate dead space or pack wounds; and to support debridement.

Question 26

What three aspects influence the type of wound management and type of dressing required?

Answer 26

Three aspects that influence the type of wound management are the causative agent, the degree of injury, and the patient's condition. The type of wound management and dressings required depend on the type, extent, and characteristics of the wound and the phase of healing.

Question 27

What are the six subscales of the Braden Scale for Predicting Pressure Sore Risk?

Answer 27

The six subscales of the Braden Scale for Predicting Pressure Sore Risk are; sensory perception, moisture, activity, mobility, nutrition, friction and shear. Is the patient completely limited, very limited, slightly limited or no impairment in sensory perception? Is the patient constantly moist, very moist, occasionally moist or rarely moist? Is the patient bedfast, chairfast, occasionally walks or walks frequently? Is the patient completely immobile, very limited, slightly limited or no limitation? Is the patient's nutrition very poor, probably inadequate, adequate or excellent? Is friction and shear a problem, potential problem or no apparent problem? T

Question 28

How is a wound culture obtained from a secondary intention wound? How does this differ from taking a wound culture from a primary intention wound?

Answer 28

A wound culture from a secondary intention wound can be obtained by the nurse using the swab technique. 1) wound exudates 2) Z-technique 3) Levine's technique. The difference between taking a wound culture from a primary intention wound is that this type of wound is a closed or approximated wound so therefore the wound is not open to swab the wound tissue but if exudates is coming out of the sutures then swabbing superficial portion of the wound is how a primary intention culture would be taken. With a secondary intention would the edges are not approximated together so therefore the wound is open and the actual wound tissue can be cultured.

Question 29

Foam dressings

Answer 29

Foam dressings are non adherent hydrocolloid dressings; these need to have their edges taped down or sealed. Require secondary dressings to obtain an occlusive environment. Surrounding skin must be protected to prevent maceration. Easy to cut and fit the wound. The purpose of foam dressings are to absorb up to heavy amounts of exudate; to provide and maintain moist wound healing; to provide thermal insulation.

Question 30

The irrigating solution should flow directly into the wound without first flowing over the skin. What is the rationale for this principle?

Answer 30

RAT: To prevent contamination of clean tissue, sterile technique is required for wound irrigation because there is a break in the skin integrity

Question 31

What two aspects concerning a wound determines how “well” the wound will heal?

Answer 31

Healing Process: two major components of regeneration and repair. Regeneration is the replacement of lost cells and tissues with cells of the same type. Repair is healing as a result of lost cells being replaced by connective tissue. Repair is the more common type of healing and usually results in scar formation. (Lewis pg. 191) (Preventing Infections) There are two main aspects to controlling wound infection: preventing microorganisms from entering the wound, and preventing the transmission of blood borne pathogens to or from the client to others.

Question 32

. What must happen for a contaminated wound to heal "normally"?

Answer 32

-If the wound is contaminated, it must be converted into a clean wound before healing can occur normally

Question 33

The patient's leg and foot wounds are to be wrapped with gauze wrap (Kerlix) after dressings are applied. What principles should the nurse use when applying the wrap?

Answer 33

-Whenever possible, bandage the part in its normal position, with the joint slightly flexed. Pad between skin surfaces and over bony prominences. Always bandage body parts by working from the distal to the proximal end. Bandage with even pressure. Whenever possible, leave the end of the body part exposed. Cover dressings with bandages at least 5 cm (2 in) beyond the edges of the dressing

Question 34

Absorptive Dressing

Answer 34

Description: Transparent absorbent wafer designed to be worn 5-7 days. The acrylic layer absorbs exudates and evaporates the excess off the transparent membrane. Purpose: Maintains a transparent membrane for easy wound bed assessment, provides bacterial and shearing protection. Maintains moist wound healing. Can be used with alginates to provide packing to deeper wound beds.

Question 35

. Discuss how each of the following factors/risks to primary prevention may interfere with wound healing:

Answer 35

Malnutrition: decreased vitamin c –delays formation of collagen fibers and capillary development. Protein- decreases supply of amino acids for tissue repair. Zinc- impairs epithelialization. Obesity: Decreases blood supply in fatty tissue. Decreased blood supply: Decreases supply of nutrients to injured areas, decreases removal of exudative debris, inhibits inflammatory response. Tissue trauma: Trauma varies in intensity, ranging from serious burns or traffic accidents to the gradual, cumulative trauma that occurs with repetitive overuse of muscles and joints (such as strenuous weight lifting). Minor injuries, often no more than minor irritants, are relatively frequent. However, any traumatic event, even a minor one, affects the body's natural metabolic balance and initiates a cascade of reactions aimed at repair and restoration of function. Smoking: nicotine is a potent vasoconstrictor and impedes blood flow to healing areas. Corticosteroids: impair phagocytosis by WBCs , inhibit fibroblast proliferation and function, depress formation of granulation tissue, and inhibit wound contraction. Chemotherapy: Although chemotherapeutic agents preferentially target rapidly dividing cells, any tissue can be affected by these treatments: macrophages and fibroblasts involved in wound healing are just as susceptible to these effects as cancer cells. Tissue necrosis: is a form of cell injury that results in the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma that result in the unregulated digestion of cell components Infection: increases inflammatory response and tissue destruction.

Question 36

list and briefly explain common complications of primary intention wound healing.

Answer 36

* Adhesions- bands of scar tissue that form between or around organs. Adhesions may occur in the abdominal cavity or between the lungs and pleura. Adhesions in abdomen may cause an intestinal obstruction. * Contractures – wound contraction is a normal part of wound healing. Complications occur when there is excessive contraction resulting in deformity. Shortening of muscle or scar tissue, especially over joint, results from excessive fibrous tissue formation. * Evisceration- occurs when wound edges separate to the extent that intestines protrude through wound. * Dehiscence –separation and disruption of previously joined wound edges. Usually occurs when a primary healing site burst open. * Excess granulation tissue- excess granulation tissue may protrude above surface of healing wound. * Fistula formation- an abnormal passage between organs or a hallow organ and skin. * Infection- increase risk of infection when wound contains necrotic tissue or blood supply is decrease. * Hemorrhage –bleeding is normal immediately after tissue injury and ceases with clot formation. Hemorrhage occurs when there is a weak spot. * Hypertrophic scars- occur when an overabundance of collagen is produced during healing. * Keloid formation-great protrusion of scar tissue that extends beyond wound edges and may form tumor like masses of scar tissue.

Question 37

what are the purposes of wound irrigation?

Answer 37

Wound irrigation is the steady flow of a solution across an open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual examination. The irrigation solution is meant to remove cellular debris and surface pathogens contained in wound exudates or residue from topically applied wound care products. Compared to swabbing or bathing, wound irrigation is considered to be the most consistently effective method of wound cleansing. The goal of irrigation is to clean the wound while avoiding trauma to wound bed and minimizing risk of driving bacteria further into the wound bed.

Question 38

Nonadherent

Answer 38

a dressing designed specifically not to stick to the dried secretions of a wound. To let the wound heal and when taking it off it doesn’t disrupt the wound healing process.

Question 39

What level of risk categories and parameters does the nurse utilize in determining preventive measures once the Braden scale score is calculated?

Answer 39

-The nurse uses sensory perception, moisture, activity, mobility, nutrition, and friction and shear as the risk factor categories; a total of 23 points is possible and an adult scoring lower than 18 points is considered at risk. (B&S 922) (for this answer I was not 100% sure, it seemed like the answer to questions #1 but I couldn't find anything else, if anyone would like to add on.....)

Question 40

. Identify independent nursing measures related to daily activities and personal care that the nurse and/or patient would utilize to prevent the transmission of microorganisms.

Answer 40

-Proper hand hygiene -nail care: short, clean, well manicured, no fake nails -teach the patient not to share personal items such as toothbrush, wash cloth, towels -access to and proper use of gloves -proper medication administration -teach the patient about cleaning and disinfecting reusable supplies for the nurse: -change dressing and bandages when they are soiled or wet -dispose of materials with bodily fluids in the proper receptacle -avoid talking, coughing, sneezing over open wounds or sterile fields, and cover the mouth and nose when coughing and sneezing -use sterile technique for invasive procedures

Question 41

Hydrogels Dressings

Answer 41

A glycerin or water based nonadhesive jelly like sheets, granules, or gels are oxygen permeable unless covered by a plastic film, requires a secondary occlusive dressing. Purpose- to liquefy necrotic tissue or slough, rehydrate the wound bed and fill in dead space

Question 42

Describe the appearance of a first day post-op surgical wound healing by primary intention.

Answer 42

Approximation of incision edges, surrounding tissues pink and inflamed.

Question 43

List nursing interventions for each subscale: sensory, moisture, activity, mobility, nutrition, friction&shear.

Answer 43

Sensory-communication enhancement, visual and hearing deficit,environmental management, peripheral sensation management. Moisture-skin surveillance, positioning, skin care treatments, pressure ulcer preventions. Activity-energy management, nutrition management,sleep enhancement. Mobility-exercise therapy, joint mobility, ambulation,exercise promotion. Nutrition- nutritional monitoring, appetite, nutritional therapy and counseling. Friction & Shear-pressure ulcer prevention, topical treatments.

Question 44

Inflammation

Answer 44

Sequential reaction to cell injury

Question 45

stages of inflammation

Answer 45

vascular response cellular response exudate production healing

Question 46

causes of inflammatory response

Answer 46

``` Physical heat, cold, radiation, trauma Chemical external & internal irritants Microorganisms (infection) bacteria, viruses, fungi, parasites ```

Question 47

hyperemia

Answer 47

engorgement; an excess of blood in a part

Question 48

Neutrophils

Answer 48

1st to respond

Question 49

Fever

Answer 49

The onset is triggered by the release of cytokines.

Question 50

Systemic Signs Fever

Answer 50

``` Elevated TPR Malaise Anorexia Lymphadenopathy Increased WBC count with a shift to the left ```

Question 51

Types of Inflammation

Answer 51

``` Acute Healing occurs in 2-3 weeks Usually no residual damage Subacute Features of acute but lasts longer ```

Question 52

Regeneration

Answer 52

Is the replacement of lost cells and tissues with cells of the same type Structure, appearance, function

Question 53

Repair

Answer 53

Is healing as a result of lost cells being replaced by connective tissue. Repair is more common type of healing and usually results in scar formation. Scar Formation Platelet’s release growth factors to begin the healing process Broken down into: Primary, secondary, and tertiary

Question 54

Nursing Interventions

Answer 54

Primary, secondary, tertiary Identify rationale for each Determine areas for Collaboration Determine areas for Delegation

Question 55

RICE

Answer 55

``` Rest Use nutrients, oxygen for healing Fibrin, collagen not disrupted Ice Cold-initial for vasoconstriction Heat-after 24-48 hours Remove debris, localize inflammatory agents Compression and immobilization Promote healing-decrease inflammatory process, assist repair, decrease metabolic needs, lessen wound debris/hemorrhage Decreases localized edema Elevation- Reduce edema/pain, increase venous return, improve circulation-oxygen and nutrients for healing ```