1.3b Inflammatory

Question 1

Inflammatory response definition

Answer 1

Sequential reaction to cell injury
Fundamental type of response by the body to disease and injury, a response characterized by the classical signs of redness, edema, heat, pain

Question 2

Role of inflammatory response?

Answer 2

Neutralizes/dilutes inflammatory agent
Removed necrotic materials
Establishes an environment for healing and repair

Question 3

Inflammation does not always equal infection

INFO

Answer 3

Same regardless of injury agent or antigen
Intensity of response depends on extent/severity of injury
Response depends on the reactive capacity of the injured person
Can be local or systemic response; acute or chronic
Systemic- significant role in many disease processes

Question 4

Inflammation healing:
Acute?
Subacute?
Chronic?

Answer 4

Acute: healing
2-3 weeks without residual damage, neutrophils are predominant WBC

Subacute: lasts longer

Chronic: lasts for weeks, months or even years with persistent and repeated tissue injury, predominant BC or lymph’s and microphages. autoimmune disease, rheumatoid arthritis, osteomyelitis

Question 5

Paradoxically, the inflammatory process?

Answer 5

Paradoxically, the inflammatory process itself may cause tissue damage while it is engaged in healing and repair. Thus, inflammation may play a role in such diverse disorders as Alzheimer disease, meningitis, atherosclerosis, cystic fibrosis, asthma, cirrhosis of the liver, inflammatory bowel disease (IBD), diabetes, osteoporosis, and psoriasis.

Question 6

Inflammatory Response Clinical Manifestations

Local?

Answer 6

Local
Pain
Erythema, heat
Edema
Heat
Change in function

Question 7

Inflammatory Response Clinical Manifestations

Systemic?

Answer 7

Systemic
Increased temp, resp, pulse

Erythema

Increased WBC with shift to left (high neutrophil count)

Vascular response: inflammatory mediators (histamine, prostaglandins, leukotriene) cause vasodilation & Increased capillary permeability. Cytokines cause fever

Question 8

Wound classification
Cause?
Duration?

Answer 8

By cause:
Surgical or nonsurgical
By duration:
acute or chronic (>3 months)

Question 9

Wound classification

Depth?

Answer 9

By depth of tissue affected:

Superficial
Involves on the epidermis

Partial thickness
Wound extends into the dermis

Full thickness
Involves the subcutaneous tissue and may extend into the fascia, muscle, tendon, or bone.

Question 10

Regeneration?

Answer 10

Regeneration: replace lost tissue with same type (liver can rebuild)

Question 11

Repair?

Answer 11

Repair: replace with connective tissue; various types

Question 12

Repair: Primary intention, Initial phase?

Answer 12

Primary intention:
Initial: 3-5d, approximation, migration, fibrin meshwork. inflammatory, wound area fills with blood, clots form and platelets release growth factor area of injury composed of fibrin clots, RBCs, neutrophils, debris. Extracellular enzymes from macrophages digest fibrin. Debris are removed and remaining fibrin meshwork remains.

Maturation & scar contraction: collagen organized/remodeled avascular scar forms

Question 13

Repair: Primary intention, granulation phase?

Answer 13

Granulation: 5d-3wk, fibroblasts, surface pink vascular, edges begin to regenerate & migrate

components of granulation tissue – fibroblasts, capillary buds, WBCs, exudate, and a semifluid ground substance fibroblasts are immature CT cells, secrete collagen which we be structured into fibrous scar tissue surface is pink, full of capillary buds, at risk for dehiscence & resistant to infection. Wound edges begin to regenerate & new epithelium & migrates in a one-cell thick layer until it contacts cells from the other side begins to resemble adjacent skin

Question 14

Repair: Primary intention, maturation and scar contraction phase?

Answer 14

Maturation & scar contraction: collagen organized/remodeled avascular scar forms.
overlaps with granulation phase, can continue for extended period of time (abd surgery restricts lifting for 6 wks) myfibroblasts cause contraction

Question 15

Repair: Secondary intention

Answer 15

Secondary Intention:

• Type of healing for wounds that have large amounts of exudate, wide irregular margins & extensive tissue loss & edges can’t be approximated
• Wounds related to trauma, ulceration, and infection
• Inflammation is more significant
• Healing and granulation takes place from the edges inward and from the bottom upward; healing process like primary intention but more granulation tissue & scarring

Question 16

Repair: Tertiary intention

Answer 16

Tertiary Intention:

• Wound contaminated or left open after infection to be sutured later after infection is controlled.
• Healing occurs with delayed suturing of a wound.
• Results in a larger and deeper scar.

Question 17

Factors that inhibit healing

Hemorrhage?

Answer 17

Hemorrhage

Hematoma-collection of blood underneath the tissues.

Question 18

Factors that inhibit healing

Infection?

Answer 18

Infection
Signs of infection early, within 2-3 days.
Surgical wound infection 4-5 days.

Question 19

Factors that inhibit healing

Dehiscence?

Answer 19

Dehiscence

Skin and tissue separate due to poor wound healing.

Question 20

Factors that inhibit healing

Evisceration?

Answer 20

Evisceration
Total separation of wound layers with protrusion of visceral organs through wound opening.
Emergency situation that requires surgical repair.
Nurse to place a sterile towel soaked in NS over eviscerated area. NPO status.

Question 21

Factors that inhibit healing

Fistula?

Answer 21

Fistula
Abnormal passage between 2 organs or between an organ and outside of body.
Drainage through fistula increases risk of skin breakdown.

Question 22

Factors delaying healing

Answer 22

Inadequate blood supply= ↓supply of cells & nutrients

Obesity = ↓blood supply

Anemia = ↓oxygen supply to tissues

Infection = ↑inflammatory response & tissue destruction

Smoking = vasoconstriction

Friction = destroys granulation & separates edges

Advance age = ↓immunity, delays in tissue synthesis

Diabetes = impairs phagocytosis, tissue growth, & vascular supply

Corticosteroids =impair WBC & fibroblast function, ↓granulation & contraction

Nutritional deficiencies

Question 23

Nutrition and healing

Vit A, B C

Answer 23

Vitamin A
Aids in process of epithelialization.

Vitamin B
Coenzymes for metabolic reactions

Vitamin C
Promotes formation of collagen fibers and capillary development.

Question 24

Nutrition and healing
Protein (albumin)
Carbs
Fats
Zinc
Fluids

Answer 24

Protein (ALBUMIN)
Provides amino acids for tissue repair

Carbohydrates
Increased metabolic energy

Fats
Aids in synthesis of fatty acids and triglycerides.

Zinc
Promotes epithelialization

Increased fluids
Loss from perspiration and exudate

Question 25

Resistant pathogens

Answer 25

Multidrug resistant pathogens MRSA : Methicillin resistant Staph aureus VRE :Vancomycin Resistant Enterococci

Question 26

Resistant pathogens | isolation

Answer 26

Contact precautions Private room Hand washing before entry and upon leaving room Instruct patient, family, and visitors on isolation procedures. Box 16-2 Lemone – preventing MRSA p.480

Question 27

Nursing Care of Wounds | On admission

Answer 27

On admission: Inspect entire body Record all wounds and appearance & Measure length, width, & depth

Question 28

Nursing Care of Wounds | Wound care, primary intention healing?

Answer 28

Primary intention healing - Cleansing- Normal saline best for cleaning wounds. - Adhesive strips - Steri strips/sutures - Transparent film dressing - Dry sterile dressing (removed when drainage stops) - Medicated sprays with transparent film

Question 29

Nursing Care of Wounds | Wound care, secondary intention healing?

Answer 29

Secondary Intention healing - Dressing products: (Lemone pg 505 Table 16-2) - Clean, prevent & manage infection IRRIGATION - Manage exudate - Maintain moist environment - Protect the wound

Question 30

Pressure ulcers | what is it?

Answer 30

Pressure ulcer: - Localized injury to the skin and/or underlying tissues. - Usually over a bony prominence - Result of pressure, or pressure combined with shear/friction. - Pressure leads to prolonged ischemia to tissues. - Heals by SECONDARY intention - Common sites: sacrum, heels, ears, greater trochanter

Question 31

Risk factors for pressure ulcers

Answer 31

``` Advanced age Anemia Contractures Diabetes Elevated body temperature Immobility Impaired circulation & vascular disease Incontinence Mental deterioration Neurologic disorder Obesity Pain Prolonged surgery ```

Question 32

Pressure ulcers | injury stages?

Answer 32

Pressure injury staging box 16.3 lemone pg 505 Stage I: Intact skin with nonblanchable redness, localized Stage 2: Partial-thickness, exposed dermis, shallow with red-pink granulation. May have an intact or open/ruptured blister. Stage 3: Full-thickness tissue loss. Subcutaneous fat, slough may be visible. May include undermining and tunneling. Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Freq. undermining and tunneling. Unstageable Ulcer Base covered with slough or eschar. Can’t evaluate.

Question 33

Risk factor identification: Braden Scale

Answer 33

Most widely used risk assessment tool for pressure ulcers Developed on the basis of risk factors in a nursing home population Identifies patients at risk and allows preventative measures to be put in place Total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure development Cutoff score for onset of pressure ulcer risk for general adult population is 18. Six subscales are used.

Question 34

Nursing care for pressure ulcer

Answer 34

Referrals for wound care and nutrition Skin inspection as part of physical assessment each shift. Notify physician of skin breakdown. Documentation of findings-very specific: location, size, drainage, characteristics, staging of wound, wound care. Turn patient minimally q 2 hours. Do not position with pressure on existing wound. Assess pain/discomfort. Pressure-relief devices Incontinent patients must be kept dry.

Question 35

Pressure ulcer labs?

Answer 35

Evaluate labs WBC- inflammation, infection Proteins, albumin, prealbumin – nutritional status ESR, C-Reactive protein –inflammation Coagulation studies –bleeding Cultures & biopsies

Question 36

Define debridement?

Answer 36

Debridement | Removal of nonviable, necrotic tissue

Question 37

Define Induration

Answer 37

Induration | An abnormally firm/hard area on the skin.

Question 38

Maceration define

Answer 38

Maceration of the skin occurs when it is consistently wet. The skin softens, turns white, and can easily get infected.

Question 39

Sinus tract (tunneling wounds) define

Answer 39

``` Sinus tract (tunneling wounds) A narrow, elongated channel in the body that allows the escape of fluid ```

Question 40

Slough define

Answer 40

Slough | Yellow or white stringy substance attached to wound bed

Question 41

Undermining define

Answer 41

Undermining | A chronic skin ulcer having overhanging margins, caused by bacterial infection.

Question 42

Eschar define

Answer 42

Eschar | Black or brown necrotic tissue that must be removed for healing.

Question 43

Define Collagen Tissue?

Answer 43

connective tissue that in the skin helps in firmness, suppleness and constant renewal of skin cells. Collagen is vital for skin elasticity

Question 44

Define Epithelialization

Answer 44

Epithelialization is a process where epithelial cells migrate upwards and repair the wounded area. This process is the most essential part in wound healing and occurs in proliferative phase of wound healing

Question 45

Define granulation tissue

Answer 45

Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size

Question 46

Define necrosis

Answer 46

Necrosis is the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply

Question 47

What is hydrocolloid (DuoDERM) dressing? what does it do? what stages is it used?

Answer 47

Stages: 1, 2, 3, 4 Forms a gel when it come in contact with wound exudate forms an occlusive barrier over the ulcer while maintaining moisture, preventing infection Helps prevent friction/shear

Question 48

What is alginate (SilvaSorb/Sorbsan) dressing do? What stages?

Answer 48

Stages: 2, 3, 4 with moderate/heavy drainage, infected/uninfected wounds. Forms gel when contact with exudate. Apply dry or min draining wounds because of dehydration/delay in healing

Question 49

what is hydrofiber (Aquacel) dressing? what stage?

Answer 49

Stages 2, 3, 4 and moderate/heaving exudate. Used with infection or risk of infection Combines absorption of hydrofiber with 1.2% silver as antimicrobial

Question 50

what is hydrogel (IntraSite gel) dressing? what stage?

Answer 50

Stage 2, 3, 4. Rehydrates wound bed and decreases pain Promotes autolytic debridement

Question 51

What is transparent adhesive (OPSITE/Tegaderm) dressing? what stages?

Answer 51

``` Stages 1, 2, 3 provide moist wound setting Prevents infection Promotes reepithelialization Minimizes friction/shear ```

Question 52

What is wet to dry dressings?

Answer 52

Provides mechanical debridement

Question 53

Wound assessment checklist for documentation

Answer 53

``` Location Size Stage Drainage Undermining/tunneling Character of wound Dressings Pressure relieving devices ```