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117 Cards in this Set
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inflammatory reponse
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a sequential reaction to cell injury
neutralizes and dilutes inflammatory agent removes necrotic materials establishes an environment suitable for healing and repair |
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vascular response to injury
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arterioles in the area briefly undergo transient vasoconstriction
after release of histamine and other chemicals by the injured cells, the vessels dilate which results in hyperema, which raises filtration pressure |
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hyperemia
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increased blood flow to the area
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neutrophils
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the first leukocytes to arrive, usually within 6-12 hours
results in elevated WBC |
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shift to the left
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increased numbers of band neutrophils in circulation
commonly found in pts with acute baterial infections |
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monocytes
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second type of phagocytic cells that migrate from circulating blood
usually arrive within 3-7 days after onset of inflammation |
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lymphocytes
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arrive later at the site of injury
primary role is related to humoral and cell-mediated immunity |
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eosinophils
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released in large quantities during an allergic reaction
release chemicals that control the effects of histamine and serotonin involved in phagocytosis of the allergen-antibody complex |
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basophils
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the histamine and heparin that basophils carry in their granules are released during inflammation
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complement system
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major mediator of inflammatory reponse
functions are enhanced phagocytosis inreased vascular permeability chemotaxis cellular lysis each activated complex can act on the next, creating a cascade effect |
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prostaglandins
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substances that can be synthesized from the phospholipids of cell membranes of most body tissues, including blood cells
can be converted to arachidonic acid, which is then oxidized by two different pathways |
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cyclooxygenase metabolic pathway
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leadds to the production of PGs of the D, E, F, and I series and thromboxanes
E and I series are potent vasodilators and inhibit platelet and neutrophil aggregation |
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exudate formation
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fluid and electrolytes that move from tthe circulation to the site of injury
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clinical manifestations of response to inflammation
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redness, heat, pain, swelling, and loss of function
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acute inflammation
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the healing occurs in 2-3 weeks and usually leaves no residual damange
neutrophils are the predominant cell type at the site of infection |
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subacute inflammation
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has the features of the acute process but lasts longer
ie infective endocarditis is a smoldering infection with acute inflammation but lasts for weeks |
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chronic inflammation
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lasts for weeks, months or years
injurious agent perisists or repeatedly injures the tissue |
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serous exudate
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results from the outtpouring of fluid that has low cell and protein content
seen in early stages of inflammation or when injury is mild skin blisters, pleural effusion |
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catarrhal exudate
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found in tissues where cells produce mucous
mucous production is accelerated by inflammation response runy nose assoc with upper respiratory tract infection |
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fibrinous exudate
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occurs with increasing vasclar permeability and fibrinogen leakage into intersitial spaces
excessive amts of fibrin coating tissue surfaces may cause them to adhere adhesions |
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purulent exudate
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consits of WBCs, microorganisms (dead or alive), liqifeied dead cells, and other debris
furuncle (boil) abscess cellulitis |
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hemorrhagic exudate
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results from rupture or necrosis of blood vessel walls
it consists of RBCs that escape into tissue ie. hematoma |
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healing process
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includes two major components:
regeneration repair |
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regeneration
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the replacement of lost cells and tissues with cells of the same type
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repair
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healing as a result of lost cells being replaced by connective tissue
repair healing occurs by primary, secondary or teriary intention the more common type of healting and usually results in scarring |
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primary intention
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healing takes place when wound margins are neatly approximated
ie surgical incision or paper cut initial phase, grantulation phase, maturation phase and scar contraction |
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initial phase of primary intention
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lasts 3-5 days
the edges of the incision are first aligned and sutured in place an acute inflammatory response occurs |
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granulation phase of primary intention
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granulation (fibroblastic, proliferative, reconstructive) is the second step
lasts from 5 days to 3 weeks |
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components of granulation tissue
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proliferating fibroblasts
proliferating capillary sprouts (angioblasts) various types of wBCs exudate loose, semifluid, ground substance |
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maturation phase and scar contraction
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the maturation phase, during which scar contraction occurs, overlaps with the granulation phase
it may being 7 days after injury and continue for several months or years |
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secondary intention
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wounds that occur from trauma, ulceration and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss
may have edges that can be approximated the debris may have to be cleaned away (debrided) before healing can take place |
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Primary to secondary intention
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a primary incision may become infected creating additional inflammation
the wound may reopen, and healing by secondary intention takes place |
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tertiary intention
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(delayed primary intention)
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, allowed to granulate, and is then sutured usually results in a larger and deeper scar than primary or secondary intention |
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wound classification
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by cause
surgical or nonsurgical acute or chronic depth of tissue affected superficial partial thickness full thickness |
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superficial wound
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involves only the epidermis
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partial thickness wounds
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extend into the dermis
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full thickness wounds
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have the deepest layer of tissue destruction because they involve the subcutaneous tissue and sometimes extend nto the fascia and underlying structures such as muscle, tendon or bone
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Red Wound - Characteristics
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traumatic or surgical wound
possible presence of serosanguineous drainage pink to bright or dark red healing or chronic wounds with granulating tissue |
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Red Wound - TPurpose of reatment
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protection and gentle atraumatic cleansing
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Red Wound - Dressings and Therapy
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tranparent film dressing
(tegaderm, opsite) hydrocolloid dressing (duoderm) hydrogels (tegagel) gauze dressing with antimicrobial ointment or solution telfa dressing with antibiotic ointment |
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Yellow Wound - Characteristics
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presence of slough or soft necrotic tissue
liquid to semiliquid slough with exudate ranging from creamy ivory to yellow-green |
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Yellow Wound - Purpose of treatment
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wound cleasing to remove nonviable tissue and absorb excess drainage
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Yellow Wound - Dressings and Therapy
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wound irrigations
hydrotherapy moist gauze dressing with or w/out antibiotic or antimicrobial agent hydrocolloidal dressing hydrogel covered with gauze absorptive dressing |
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Black Wound - Characteristics
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black, gray or brown adherent necrotic tissue
possible presence of purulent drainage |
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Black Wound - Purpose of Treatment
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debridement of eschar and nonviable tissue
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black wound - dressings and therapy
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topical enzyme debridement
surgical debridement hydrotherapy chemical debridement moist gauze dressing hydrogel covered with gauze absorptive dressing covered with gauze |
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Vitamin C deficiency
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delays formation of collagen fibers and capillary development
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Protein deficiency
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decreases supply of amino acids for tissue repair
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Zinc deficiency
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impairs epithelialization
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inadequate blood supply
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decreases suppy of nuttrients to injured area
decreases removal of exudative debris inhibits inflammatory response -diabetics on extremities further from the heart |
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Corticosteroid drugs
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impair phagocytosis by WBCs
inhibit fibroblast proliferation and function depress formation of granulation tissue inhibit wound contraction |
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Infection
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increases inflammatory response and tissue destruction
have to get infection and nonviable tissue out |
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Smoking
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nicotine is a potent vasoconstrictor and impeds blood flow to healing process
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mechanical friction on wound
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destroys granulation tissue
prevents apposition of wound edges |
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Advanced Age
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slows collagen synthesis by fibroblats
impairs circulaton requires longer time for epithelialization of skin alters phagocytic and immune responses |
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Obesity
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Decreases blood supply in fatty tissue
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Diabetes Mellitus
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Decreases collagen synthesis
retards early capillary growth impairs phagocytosis (result of hyperglycemia) reduces supply of o2 and nutrients secondary to vascular disease |
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Poor general health
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causes generalized absence of factors necessary to promote wound healing
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anemia
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supplies less oxygen at tissue level
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factors delaying wound healing
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vitamin C deficiency
protein deficiency zinc deficiency inadequate blood supply corticosteroid drugs infection smoking mechanical friction on wound advanced age obesity diabetes mellitus poor general health anemia |
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hypertrophic scar
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inappropriately large, red, raised and hard
remains confined to the wound edges and regresses in time |
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Keloid
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a greater protursion of scar tissue that extends beyond the wound edges and may form tumorlike masses
permanent, without tendency to subside |
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contracture
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wound contraction is necessary for healing but this process can become abnormal when there is excessive contraction reulting in deformity or contracture
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dehiscence
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the separation of disrupttion of previously joined wound edges
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three possible contributing causes of dehiscence
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1) an infection may cause an inflammatory process
2) the granulation tissue may not be strong enough to withstand the forces imposed on the wound 3) obese individuals are at high risk for wound dehiscence because adipose tissue interferes with healing |
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evisceration
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occurs when wound edges separate to the extend that intestings protrude though the wound
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excess granulation tissue
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may protrude above the surface of the healing wound
if the granulation tissue is cauterized or cut off, healing continues in a normal manner |
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adhesions
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bands of scar tissue between or around organs
may occur in the ab cavity, or betwen the lungs and pleura |
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adhesions in the abdomen
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may cause an intestinal obstruction
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adhesions between the lungs and pleura
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require decortication, or stripping of pleura, to permit normal ventilation
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drug therapy
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used to decrease the inflammatory response
antihistamines may also be used to inhibit the action of histamine |
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nutritional therapy
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a high fluid intake is needed to replace fluid loss from perspiration and exudate formation
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antipyretic drugs
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salicylates (aspirin)
acetaminophen nsaids (ibuprofen, motrin, advil) |
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antiinflammatory drugs
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salicylates
corticosteroids nsaids |
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Vitamins
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vitamin a
vitamin b complex vitamin c |
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salicylates
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lower temp by action on heat regulating center in hypothalamus
resulting in peripheral dilation and heat loss interfere with formation and release of PGs selectively depress CNS reduce capiallary permeability |
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acetaminophen
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lowers temperature by action on heat-regulating center in hypothalamus
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nsaids
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inhibit syntheses of PGs
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corticosteroids
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interfere with tissue granulation
induce immunosuppressive effects (decreased synthesis of lymphocytes) prevent liberation of lysosomes |
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vitamin A
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accelerates epithelialization
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Vitamin B complex
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acts as coenzymes
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Vitamin C
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assists in synthesis of collagen and new capillaries
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Vitamin D
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facilitates calcium absorption
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inflammation - implementation
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best management of inflammation is prevention of infection, trauma, surgery and contact with potentially harmful agents
adequate nutrition is essential |
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observation and vitals
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ability to recognize the manifestations of inflammation is important
classic manifestations in immunosuppressed may be masks vital signs important |
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moderate fevers
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up to 103 usually produce few problems in most patients
if the patient is very young or very old, is extremely uncomfortable or has a significant medical problem, antipyretics should be used |
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RICE
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rest
ice compression elevation key concept in treating soft tissue injuries |
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rest
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helps the body better use its nutrients and oxygen for healing
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cold and heat
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cold appplication appropriate initially to cause vasoconstriction and decrease swelling, pain and congestion from increased metabolism in area of inflammation
heat used later (after 24-48 hrs) to promote healing by increasing the circulation to the inflamed site and subsequent removal of debris |
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compression and immobilization
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promote healing by decreasing the inflammatory process
assisting in the repair process decreasing metobolic needs |
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elevation
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will reduce the edema at the inflammatory site and incease venous return
helps reduce pain and improve ciculation of blood, which provides the oxygen and nutrient needed for healing |
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wound healing - assessment
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Use clock form
wound should be measured the consistency, color, and odor of any drainage should be recorded and reported if abnormal for the situation |
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purposes of wound management
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1) cleaning a wound to remove any dirt and debris from wound bed
2) treat infection to prepare the wound for healing 3) protect a clean wound from trauma so it can heal normally |
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wound healing management by primary intention
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common to cover the incision with a dry, sterile dressing that is removed as soon as the drainage stops or in 2-3 days
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wound healing managment by secondary intention
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depends on the wound etiology and type of tissue in the wound (red, yellow, black)
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Debridement methods
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surgical
mechanical autolytic enzymatic |
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negative pressure wound therapy
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vacuum assisted wound closure -
uses suction to remove drainage and speed wound healing for acute or traumatic wounds, surgical wounds that have dehisced, pressure ulcers and chronic ulcers |
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hyperbaric oxygen therapy
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deliver of O2 at increased atmospheric pressure or by creating chamber around the limb
90-120 minutes long |
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infection prevention and control
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pt should not touch wound
keep free from contamination antibiotics may be given if infection developsl, culture |
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psychological implications
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pt needs to understand they healing process and normal changes that occur as wound heals
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patient teaching includes
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how to care for wound
it might take 4-6 weeks adequate rest good nutrition observe for complications report abnormal healing drug-specific side effects |
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pressure ulcer
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localized area (usually over a bony prominence) of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues
fall under category of healing by secondary intention |
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pressure ulcer common sites
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sacrum and heels
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factors that influence development of pressure ulcers
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amount of pressure (intensity)
lenth of time pressure is exerted on the skin (duration) ability of patient tissue to tolerate the pressure shearing force friction excesive moisture |
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shearing force
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pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement
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Stable eschar on heels
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stable (dry, adherent, intact) eschar on the heels serves as the body's natural biological cover, and should not be removed
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braden scale
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risk assessment
scores range from 6-23 the lower the numeric score, the higher the patient's predicted risk of developing a pressure ulcer |
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braden scale scores
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19-23 no risk
15-18 at risk 13-14 moderate risk 10-12 high risk 9 or below very high risk |
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overall goals for patient with pressure ulcer
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1) have no deterioration of the ulcer stage
2) reduce or eliminate the factors that lead to pressure ulcers 3) not develop an infection in the pressure ulcer 4) have healing of pressure ulcers 5) have no recurrence |
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local care of pressure ulcer may involve...
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debridemet
wound cleaning applicaion of dressing relief of pressure |
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pressure ulcer with necrotic tissue or eschar (except dry, stable, necrotic feet or heels)
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must have the tissue removed by either surgical, mechanical, enzymatic or autolytic debridement methods
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After pressure ulcer has been debrided
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the goal is to provide an appropriate wound environment that supports mose wound healing and prevents disruption of the newly formed granulation tissue
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Solutions for pressure ulcers
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Dakin's solution (sodium hypochlorite solution), acetic acid, povidone-iodine, and hydrogen peroxide are cytotoxic and should not be used
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irrigation pressure for pressure ulcers
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use enough irrigation pressure to adequately clean the pressure ulcer (4-15 psi)without causing traumka or damate to the wound
can use 30ml syringe with 19-gauge needle |
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pressure ulcers and selection of dressing
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mainenance of moist environment
prevention of wound desiccation (drying out) ability to absorb the wound drainage location of wound amount of caregive time cost of dressing presence of infection clean vs sterile dressing care delivery setting |
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wet-to-dry dressings and pressure ulcers
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should never be used on a clen granulating pressure ulcer
this type of dressing should be used only for mechanical debridement of the wound |
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contaminated pressure ulcers
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stages II through IV pressure ulcers are considered to be contaminated or colonized with bacteria
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