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108 Cards in this Set

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  • Back
A sequential reaction to cell injury
Inflammatory response
________is always present with infection
Inflammation
_________is not always present with inflammation
infection
involves invasion of tissues or cells by microorganisms such as bacteria, fungi, and viruses.
Infection
can be caused by nonliving agents such as heat, radiation, trauma, and allergens.
inflammation
what are the four phases of the inflammatory response?
vascular response
cellular response
formation of exudate
healing
what occurs during the vascular response?
arterioles in the area BRIEFLY vasoconstrict, but vessels dilate after the release of histamine, this increases the blood flow to the ares.
Hyperemia
increased blood flow in the area
how do blood clots help in the inflammation process?
they function to trap bacteria, to prevent their spread, and to serve as a framework for the healing process.
chemotaxis
directional migration of white blood cells along a concentration gradient of chemotactic factors, which are substances that attract leukocytes to the site of inflammation.
are the first to arrive (usually within 6-12 hours)
Neutrophils
What is the purpose of neutrophils?
they engulf bacteria, other foreign material, and damaged cells.
what is the lifespan of neutrophils?
24-48 hours
what is another name for immature form of neutrophils?
bands
what is another name for mature neutrophils?
segmented neutrophils
what does "shift to the left" mean?
the finding of increased numbers of band neutrophils in circulation
which types of patients will you commonly find "shift to the left" increase of WBC's?
patients with acute bacterial infections
what are the second type of phagocytic cells that migrate from circulating blood to the inflammation area?
And within how many days to they arrive to the site of inflammation?
Monocytes
they arrive 3-7 days after the onset of inflammation
what happens to monocytes upon entering the tissue spaces?
transform into macrophages
what is the primary role of the monocytes (newly transformed macrophages)?
assist in phagocytosis of the inflammatory debris
what is the third leukocyte to arrive at the site of inflammation?
Lymphocytes
what is the primary role of the lymphocytes?
is related to humoral and cell-mediated immunity
What is released in large quantities during an allergic reaction?
Eosinophils
What do Eosinophils do?
they release chemicals that act to control the effects of histamine and serotonin.
are involved in phagocytosis of the allergen-antibody complex
Eosinophils
have highly caustic chemicals that are capable of destroying a parasite's cells surface?
Eosinophils
Histamine and heparin are carried by _______and are released during inflammation
Basophils
what are the major functions of the complement system?
enhanced phagocytosis
increased vascular permeability
chemotaxis
cellular lysis
_____can be synthesized from the phospholipids of cell membranes of most body tissues, including blood cells
prostaglandins (PGs)
consists of fluid and leukocytes that move from the circulation to the site of injury.
exudate
what is the local response to inflammation?
redness
heat
pain
swelling
loss of function
what are the systemic manifestations of inflammation?
increased WBC with a shift to the left
malaise
nausea and anorexia
increased pulse and respiratory rate
fever
the onset of fever is triggered by the release of
cytokines
what are the beneficial aspects of fever?
increased killing of microorganisms, increased phagocytosis by neutrophils, and increased proliferation of T cells. also enhances the the activity of interferon
what are the basic types of inflammation?
acute
subacute
chronic
in acute inflammation, when does healing occur?
2-3 weeks
what is the predominant cell type in acute inflammation?
Neutrophils
what happens with subacute inflammation, and what is an example?
it has the same features of the acute process but lasts longer; ex: infective endocarditis;
how long does subacute inflammation persist?
weeks or months
how long does chronic inflammation last for?
weeks, months, or even years
what are the predominant cell types present at the site of inflammation for chronic inflammation?
lymphocytes and macrophages
what are examples of chronic inflammation?
Rheumatoid arthritis and TB
What are the two components of the healing process?
regeneration
repair
The replacement of lost cells and tissues with cells of the same type
Regeneration
healing as a result of lost cells being replaced by connective tissue
Repair
which organ injuries are typically followed by rapid regeneration?
skin, lymphoid organs, bone marrow, and mucous membranes of the GI, urinary and reproductive tracts.
which organs have stable cells that retain their ability to regenerate but do so only if the organ is injured?
liver, pancreas, kidney, and bone cells
What are the three types of healing with Repair?
primary intention
secondary intention
tertiary intention
healing takes place when wound margins are neatly approximated, such as in a surgical incision or a paper cut
Primary intention
what are the three phases of Primary intention healing?
Initial
granulation
scar contracture
what happens in the initial phase of primary intention healing?
approimation of incision edges; migration of epithelial cells; clot serving as meshwork for starting capillary growth
what happens in the granulation phase of primary intention healing?
migration of fibroblasts; secretion of collagen; abundance of capillary buds; fragility of wound
what happens in the scar contracture phase of primary intention healing?
remodeling of collagen; strengthening of scar
How long is the initial phase of primary intention healing?
3-5 days
How long is the granulation phase of primary intention healing?
5 days to 4 weeks
How long is the scar contracture phase of primary intention healing?
7 days to several months
the scar may be more painful at this phase than in the granulation phase of primary intention healing?
scar contracture
Secondary intention wounds occur from what type of injury?
trauma, ulceration, and infection that has large amounts of exudate and wide, irregular wound margins with extensive tissue loss.
what is the major difference in primary and secondary intention healing?
the greater defect and the gaping wound edges with the secondary intention wounds.
how does healing and granulation take place in the secondary intention wound?
it takes place from the edges inward and from the bottom of the wound upward until the defect is filled.
Delayed primary intention healing that occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together
tertiary intention healing
when does tertiary intention healing occur?
when a contaminated wound is left open and sutured closed after the infection is controlled. also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured.
How can wounds be classified?
by their cause
or by the depth of tissue affected
What are example of wound causes?
surgical or nonsurgical
acute or chronic
what are examples of wound depth of tissue affected?
superficial
partial thickness
full thickness
superficial wounds involve which layer of the skin?
epidermis only
partial-thickness wounds involve which layer(s) of the skin?
They extend into the dermis
Full-thickness wounds involve which layers of the skin?
have the deepest layer of tissue destruction involving the subcutaneous tissue and sometimes extend into the fascia and underlying structures such as muscle, tendon, or bone
What are the three different wound colors?
red
yellow
black
Color classification of wounds can only be applied to which level of healing intention?
secondary
what are certain factors that can interfere with wound healing and lead to complications?
malnutriction, obesity, decreased blood supply, tissue trauma, smoking, drugs(corticosteroids +chemotherapy), wound debris such as necrotic tissue and infection.
what are some complications that may occur with healing?
hypertrophic scars and keloids
contracture, dehiscence, excess granulation tissue, adhesions and major organ dysfunction.
how do hypertrophic scars and keloid formation occur?
when the body produces excess collagen tissue
an inappropriately large, red, raised, and hard scar
hypertrophic scar
great protrusion of scar tissue that extends beyond the wound edges and may form tumor-like masses
Keloid
is necessary for healing; a shortening of muscle or scar tissue results from excessive fibrous tissue formation, especially if the wound is near a joint
contracture
contracture frequently occurs in an area that has what type of injury?
burn
separation and disruption of previously joined wound edges
dehiscence
Dehiscence usually occurs when?
a primary healing site bursts open
What are the three possible contributing causes of dehiscence?
infection may cause inflammatory process; granulation tissue may not be strong enough to withstand the forces imposed on the wound; obesity due to adipose tissue interfering with healing
occurs when wound edges separate to the extent that intestines protrude through the wound
evisceration
"proud flesh" is another term for what?
excess granulation tissue
bands of scar tissue between or around organs
adhesions
what is needed to correct the negative nitrogen balance resulting from the increased metabolic rate?
protein
what is needed for the increased metabolic energy required in inflammation and healing?
carbohydrates
what is a necessary component in the diet to help in the synthesis of fatty acids and triglycerides, which are part of the cellular membrane?
fats
what is needed for capillary synthesis and collagen?
vit C
what vitamins are necessary as coenzymes for many metabolic reactions?
B-complex vitamins
which vitamin is needed in healing because it aids in the process of epithelialization?
Vit A
what is the best management of inflammation?
the prevention of infection, trauma, surgery, and contact with potentially harmful agents
which individuals are at risk for wound-healing problems?
malabsorption problems (crohn's, liver disease and GI surgery), deficient intake or high energy demands (malignancy, major trauma or surgery, sepsis, fever) and diabetes patients
if a wound infection develops in a post-op patient, how soon will the vital signs show a change?
3-5 days after surgery
what is the most important aspect of fever management?
determining its cause
a localized area (usually over a bony prominence) of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues
pressure ulcer
what is the most common site for pressure ulcers?
sacrum and heels
What are factors that influence the development of pressure ulcers?
amount of pressure (intensity)
length of time pressure is exerted on skin(duration) and the ability of the patient's tissue to tolerate the externally applied pressure
pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement
shearing force
Which patients are at a higher risk for the development of pressure ulcers?
elderly, incontinent, bed-or wheelchair-bound, or recovering from spinal cord injuries
when can the "true" depth and stage of an ulcer be determined?
when enough slough and/or eschar is removed to expose the base of the wound.
what is the most common complication of a pressure ulcer?
recurrence
what is the score range on the braden scale?
6-23
what are the six subscales included in the braden scale?
sensory perception
moisture, activity, mobility, nutrition and friction + shear
what is the primary nursing responsibility
to identify patients at risk for developing pressure ulcers and implementing pressure ulcer prevention strategies for those identified as being at risk
what remains the BEST treatment for pressure ulcers?
prevention
which solutions should not be used to irrigate or clean a pressure ulcer?
Dakin's solution, acetic acid, povidone-iodine, hydrogen peroxide--because they are all cytotoxic.
How much pressure (psi) should be used to adequately clean and irrigate a pressure ulcer?
4 to 15 psi
How can a nurse obtain 4 to 15 psi when irrigating or cleaning a pressure ulcer?
by using a 30 mL syringe and a 19 guage needle
when should a wet-to-dry dressing be used for pressure ulcers?
only for mechanical debridement of the wound. Should never be used on a clean, granulating pressure ulcer