HN--ch.12: inflammation

what are the different methods of prevention?

-teaching -mobilizing -skin care: remove excessive moisture, avoid massage over bony prominences, turn every 1-2 hrs (avoiding shearing), use lift sheets, position with pillows or elbow/heel protectors, use specialty beds, cleanse skin from incontinence, use absorbent pads or briefs -nutrition: caloric intake elevated, blood sugar control, supplements

the intensity of the inflammatory responds depends on?

-the extent and severity of injury -the reactive capacity of the injured person

what are some complications of healing?

-the shape and location of the wound -inadequate nutrition, smoking, pressure ulcers, incontinent, infection--all certain factors that can interfere with wound healing and lead to complications

how to wet-to-dry dressings work

-traps necrotic or nonviable tissue in dressing as it dries -moist upon application, dries for 4-6 hrs -gently removed when moist with absorbed drainage and nonviable tissue

what is RICE? what type of injuries does it treat?

-treats soft tissue injuries and related inflammation -Rest: use nutrients and oxygen -Ice: initially after 24-28 hrs, then apply heat -Compression -Elevation: above the level of the heart

assessing pressure ulcers

-upon admission -periodic intervals -every 24 hrs in acute care -in long term care: check weekly for first month, then monthly checks or quarterly

alternative therapies for pressure ulcers

-vacuum-assisted closure -electrical stimulation -hyperbaric oxygen therapy

how do negative pressure wound therapy work

-vacuum-assisted wound closure -suction removes drainage and speeds healing -monitor serum protein level, F&E balance, and coagulation studies -common for pressure ulcers or wounds

how can the inflammatory response be divided?

-vascular response -cellular response: neutrophils, monocytes, lymphocytes -formation of exudate -chemical mediators: complement system, prostaglandins and leukotrienes -healing

goals related to pressure ulcers: to keep skin clean and healthy and prevent occurrence

-wash with mild soap, blot dry -inspect frequently -keep well hydrated -use topical creams -avoid wrinkles in sheets/clothes

how to dress primary intention wounds

-with dry sterile dressing, removed as soon as drainage stops -drains may be inserted -topical antimicrobials/antibacterials should be used with caution since they can delay wound healing

what is secondary intention?

-wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss -edges cannot be approximated -results in more debris, cells, and exudate

A basic principle of wound management for all open wounds is to A. Protect new granulation and epithelial tissue. B. Apply topical antimicrobials to prevent wound infection. C. Remove wound exudate with frequent dressing changes. D. Use occlusive dressings to prevent wound contamination.

Answer: A b. New granulation tissue would be compromised with topicals c. Exudate would cause drain and debridement d. Occlusive dressings used for heavy to moderate drainage, not applicable as basic principle

What is the most important nursing intervention for the prevention and treatment of pressure ulcers? A. Using pressure-reduction devices B. Massaging pressure areas with lotion C. Repositioning the patient a minimum of every 2 hours. D. Using lift sheets and trapeze bars to faciliate patient movement

Answer: C

What nutrients aid in capillary snthesis and collagen production by the fibroblasts in wound healing? A. Fats B. Proteins C. Vitamin C D. Vitamin A

Answer: C

What is the primary difference between healing by primary intention and healing by secondary intention? A. Secondary healing requires surgical debridement for healing to occur B. Primary healing involves suturing two layers of granulation tissue together C. Presence of more granulation tissue in secondary healing results in more scarring D. Healing by secondary intention takes longer because more steps in the healing process are necessary.

Answer: C A. describes tertiary, not secondary B. describes tertiary healing, granulation is already healing

Which patient is the greatest risk for developing pressure ulcers? A. A 42-year old obese woman with type 2 diabetes B. A 78-year old man who is confused and malnourished C. A 30-year old man who is comtase following a head injury D. A 65-year old woman who has urge and stress incontinence

Answer: C, because comatose, neurological injury B is second best because malnourishment D might be able to walk, likely to only have problems in perineal areas Then lastly, A

The nurse cares for a patient with a clean wound that has formed granulation tissue. Which, if selected by the nurse, would be most appropriate for this patient? A. Allow the wound to dry by leaving open to air. B. Apply an absorption dressing to remove exudate. C. Debride the granulation tissue with a dry dressing. D. Keep the tissue moist with a transparent film dressing.

Answer: D B not correct because of the exudates

Which nursing intervention for a patient with a Stage IV sacral pressure ulcer are most appropriate to assign or delegate to a LPN (select all that apply) A. Assess and document wound appearance B. Teach the patient pressure ulcer risk factors C. Choose the type of dressing to apply to the ulcer D. Measure the size (width, length, depth) of the ulcer E. Assist the patient to change positions at frequent intervals

Answer: D, E a. assesses b. teaches, but can reteach or enforce c. uses judgement

what does a low score on the Braden scale tell you?

lower score=lower level of function=higher risk for pressure ulcers

what is a keloid scar?

scarring beyond wound edges, looks like a tumor

Braden scale

used for systematic skin inspection; categories: -sensory perception -moisture -mobility -nutrition -friction and shear

what are clinical manifestations for local response of the inflammatory response?

-erythema (redness) -heat -pain -swelling: vasodilation forcing fluid in the interstitial spaces -loss of function

physiologic implications for the patient with a wound

-fear of scar or disfigurement -drainage or odor concerns -be aware of your facial expression while doing dressing changes

goals related to pressure ulcers: to prevent or relieve pressure and stimulate circulation

-frequent change of position; 1-2 hrs -pressure relieving mattresses -memory foam mattresses or gel pads in chairs -avoid trauma to skin -head of bed less than 30 degrees

stage III pressure ulcers

-full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia -presents as a deep crater with possible undermining of adjacent tissue -depth of ulcer varies by anatomic location

stage IV pressure ulcers

-full-thickness loss can extend to muscle, bone, or supporting structures -bone, tendon, or muscle may be visible or palpable

how to measure wounds

-head to toe -side to side -depth: tunneling or undermining -clock like pattern; head=12 o clock, toes=6 o clock

what is the final phase of the inflammation process?

-healing

nursing implementation

-health promotion: prevention of injury, adequate nutrition, early recognition of inflammation, immediate treatments, prevention of infection, complications of infection and signs of inflammation as means for patient teaching

how to cleanse a wound

-horizontal wound: center outwards, then laterally -vertical wound: top to bottom, then laterally -drain or stab wound: circular motion

what are clinical manifestations for systemic response of the inflammatory response?

-increased WBC count with a shift to the left (leukocytosis) -malaise -nausea and anorexia -increased pulse and respiratory rate -fever--chills and shivering, body is hot, yet person seeks warmth until the circulating temperature reaches core body temperature

nutritional needs for ulcer care

-increased carbs and protein -increased vitamins C and zinc

stage I pressure ulcers

-intact skin with non blanachbel redness -possible skin indicators: skin temp, tissue, consistency, pain -may appear with red, blue, or purple hues in darker skin tones

signs of pressure ulcer infection

-leukocytosis -fever -increased ulcer size, odor, or drainage -necrotic tissue -pain

assessing pressure ulcers in patients with darker skin

-look for areas of skin darker (purplish, brownish, bluish) than surrounding skin -use natural or halogen light for accurate assessment (fluorescent light casts a blue color, skewing results) -assess skin temp with hand: ulceration may be warm initially then be cooler -touch for consistency: boggy or edematous tissue may indicate stage I -ask about pain or itchy sensation

how do moisture retention dressings work

-maintain moisture to promote healing and prevent damage to healing tissue -dressing is coated with gel, colloids, or antibacterial preparations to prevent skin maceration and promote healing -may be used to assist in debridement of wounds or to protect healthy tissue during healing process

nursing acute interventions

-observation -vital signs: fever, HR, RR -fever management: harder tine or delayed symptoms in elderly, elderly NSAID use

what is evisceration?

-occurs when wound edges separate to the extent that intestines protrude through the wound -has to be resutured -make sure organs stay moist and sterile

stage II pressure ulcers

-partial-thickness loss of dermis -shallow open ulcer with red pink wound bed -presents as an intact or ruptured serum-filled blister

what can a UAP do with wounds?

-perform dressing changes for chronic wounds using clean technique -empty wound drainage containers and document drainage on intake and output record -report changes in wound appearance of drainage to RN

what is the best ways to not get ulcers?

-prevention! -ID risk factors and implement prevention strategies

what are the three type of of repair?

-primary intention -secondary intention -tertiary intention

how to dress red wound

-protect the wound -topical antibiotic -nonadhering dressing -keep moist (moisture retention dressing; dry dressing can damage granulation tissue)--don't air dry or dry out

complications of pressure ulcers

-recurrence -cellulitis -chronic infection -osteomyelitis (bone infection)

what are the two major components of healing?

-regeneration: replacement of cells -repair: healing as a result of lost cells being replaced with connective tissue, more common, can cause scar formation

where are the most common sites for pressure ulcers?

-sacrum -heels

what is dehiscence?

-separation and disruption of previously joined wound edges -usually occurs when a primary healing size bursts open -has to be resutured

what is the inflammatory response?

-sequential response to cell injury -neutralizes and dilutes inflammatory agent -removes necrotic materials -establishes an environment suitable for healing and repair -mechanism of inflammation basically the same regardless of injuring agent

what do you need to document about an ulcer?

-size, stage, location, exudate, infection, pain, tissue appearance

goals related to pressure ulcers: promote healing of pressure ulcers

-special support surfaces like mattresses and cushions -nutritional supplements -wound care dressings: exudate absorbing, deriding, hydrating, antimicrobial, wound assisted closure-vacuum therapy -keep area dry -use skin barriers as needed -observe for signs of infection

how is fever beneficial? when is it present?

-systemic response to infection -beneficial since it increases killing of microorganisms, increased phagocytosis, and increased proliferation of T lymphocytes

what to teach a patient in regards to wounds?

-teach signs and symptoms of infection -note changes in wound color or amount of drainage -provide medication teaching

what is friction

two surface rubbing against each other

common nutritional therapy for wound healing

-diet high in protein, carbs, and vitamins, with moderate fat -vitamin C -vitamin B: metabolic creation -vitamin A: epithelialization

methods of infection prevention

-don't touch recently injured area -keep environment free from possibly contaminated items -antibiotics may be given prophylactically

common drug therapy for wound healing

-Becaplermin (Regranex)

what is bandemia?

-a shift to the left -more bands are present

what is a fistula formation?

-abnormal passage between organs or a hollow organ and skin

how to dress yellow wounds

-absorption dressing -requires cleaning to heal -dressing that absorbs exudate and cleanses the wound surface -hydrocolloid dressings

what risk factors influence ulcers?

-advanced age -anemia -contractures -diabetes mellitus -elevated body temp -immobility -impaired circulation -incontinence -low diastolic BP (<60 mm Hg) -mental deterioration -neurologic disorder -obesity -pain -prolonged surgery -vascular disease

what are the influencing factors on pressure ulcers?

-amount of pressure (intensity) -length of time pressure is exerted (duration) -ability of tissue to tolerate externally applied pressure -shearing force -friction -excessive moisture

drug therapy for inflammation/infection

-aspirin -acetaminophen -NSAIDs: naproxen, ibuprofen, advil, motrin -corticosteroids

when/what to assess on wounds?

-assess on admission and on a regular basis -ID factors that may delay healing -look at the consistency, color, odor, and drainage

what to teach the patient/caregiver for prevention of ulcers

-assess skin at regular intervals -linen change with incontinence -correct positioning -dressing changes -adequate nutrition -daily skin inspection -never directly over ulcer

how are wounds classified?

-by their cause: surgical or nonsurgical, acute (rapid) or chronic (over two weeks) -depth of tissue affected: superficial (epidermis), partial thickness (extends into the dermis), or full thickness (deepest layer, sometimes involves subcutaneous tissues and underlying structures) -color: red, yellow, black (least desirable) -- can have 2+ colors

methods of infection control

-culture and sensitivity test should be done to determine organism and best antibiotic -done when there's drainage and before first dose of antibiotics -concurrent swab specimens obtained from: wound exudate, Z technique, Levine's technique

how to dress black wounds

-debridement of nonviable, eschar tissue

medical and surgical care for pressure ulcers

-debridement: surgical, mechanical, enzymatic and autolytic -wound cleansing: normal saline solution, keep wound moist, avoid use of antiseptic b/c they're cytotoxic (Dakin's solution, iodine, hydrogen peroxide) -dressings: protect wound, biocompatabile, hydrate--moistened cause, transparent film, hydrocolloid (moisture and oxygen retaining)

what is tertiary infection?

-delayed primary intention due to delayed suturing of the wound -two layers of granulation sutured closed, results in an even larger scar -occurs when a contaminated wound is left open and sutured closed after the infection is controlled

how do hyperbaric O2 therapy (HBOT) work

-delivery of O2 at increased atmospheric pressure, 3x normal level -allows O2 to diffuse into serum -90-120 minutes, 10-60 treatments -accelerates granulation tissue and wound healing

how to dress secondary intention wound care

-depends on etiology and type of tissue that is in the wound

what is primary intention?

3 phases: -initial phase: fresh incision, edges are aligned, blood fills the incision are, which forms matrix for WBC migration, acute inflammatory reaction occurs -granulation phase: viable for dehiscence, pink and grainy; fibroblasts migrate to site and secrete collagen, surface epithelium begins to regenerate -maturation phase and scar contraction: overlaps with granulation phase, fibroblasts disappear as wound becomes stronger -ex: surgical incision or paper cut

T/F infection is always present with inflammation

false; infection is not always present with inflammation

a patient that come in acting strange, with no fever is typically suffering from a ______ and is classified as ______

UTI, altered mental status

what is a pressure ulcer?

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

what causes hypertrophic scarring?

an overabundance of collagen

how are ulcers staged?

based on the deepest level of tissue damage -stage I is minor -stage IV is severe

planning with ulcers

overal goals -no deterioration -reduce contributing facts -not develop an infection -have healing -have no recurrence

what is shearing force?

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

T/F inflammation is always present with infection

true