An enzyme cascade consisting of two pathways to mediate inflammation and destroy invading pathogens Functions of this system are: enhanced phagocytosis, increased vascular permeability, chemo-taxis, and cellular lysis.
Local Manifestations of Inflammation
loss of function (functio laesa)
Local manifestations of Inflammation
-Heat and redness are the result of vasodilation and increased blood flow through the injured site
-Swelling occurs as exudate (fluid and cells) accumulate in the tissues
-Swelling is usually accompanied by pain caused by pressure exerted by exudate accumulation
producing or containing pus
Results from outpouring of fluid: early stages of inflammation or when injury is mild
Found during the midpoint of healing, after surgery or tissue injury. Composed of RBC's and serous fluid. This fluid is semiclear pink and may have streaks.
Different from fibrosis, which is a sign of chronicity, this type of exudate occurs when there is vascular damage and leakage of fibrinogen into the surrounding tissues. Implies a severe inflammatory process.
inflammation of less than two weeks duration often associated with bacterial infections and usually characterized by the presence of neutrophils, monocytes, and macrophages
healing lasts longer than 2-3 weeks, but usually leaves no residual damage. ex. infective endocarditis
an infection of the endocardial surface of the heart.
ex), 31 y/o WM seen in ER c/o Fever, night sweats. + IV drug use, and cardiac murmur. ECG reveals prolonged PR interval, and left bundle branch block. Patient stated he had a recent strep or staph bacterial infection but not sure which one. Stated he did not get ABT filled. Prescription given by PCP was 10days worth of PCN. What is your inital thought?
a rise of body temperature above the normal. It is caused by cytokines produced in response to infection.
inflammation of prolonged duration or slow progress marked histologically by an infiltration of mononuclear cells (lymphocytes, macrophages, plasma cells) es. Rheumatoid arthritis and osteomyelitis, can lead to autoimmune disorders
Nx Diagnosis for the patient with inflammation include
Acute pain r/t injury, inflammatory process
Hyperthermia r/t increased metabolic rate, trauma
Risk for imbalanced body temp r/t infection and inflammatory process
nursing implementation of inflammation
The prevention of infection, trauma, surgery, and contact w/ potential harmful agents.
nursing implementation of inflammation
Adequate nutrition- essential, so the body as ness factors needed for healing
high fluid intake to replace fluid loss
Early recognition so appropriate tx can begin
nursing implementation of inflammation
If immunosuppressed (eg, taking corticosteroids or receiving chemo), inflammation may be masked.
S/S may be malaise or "just feeling tired".
OBSERVE VITAL SIGNS: (ESP W/ INFECTION)
Lower body temp to relieve anxiety
may benefit host defense mechanisms
antipyretic drus are rarely essential
moderate fever 103* (up to) usually produce few problems
Pt very young, very old, extremely uncomfortable or has a significant med problem. THE USE OF ANTIPYRETICS SHOULD BE CONSIDERED.
In the immunosuppressed pt should be treated rapidly and antibiotic iv therapy begun, bc infection can progress rapidly to septicemia.
Drug therapy for fever
Asprins block PG synthesis in the hypothalamus n everywhere else in the body
Acetaminophen- acts on the heat regulating center in the hypothalamus
NSAIDS- (ibuprofen, motrin, advil)- have antipyretics
corticosteroids- are antipyretic through dual mechanism... prevent cytokine production and PG synthesis.
THE ACTION OF THESE DRUGS RESULT I DILATION OF SUPERFICIAL BLOOD VESSELS, INCREASED SKIN TEMP, AND SWEATING.
Should be given round the clock to prevent acute swings in skin temp/ admin in 2-4 hr intervals
Cold application may be used at the inital trauma to cause vasoconstriction and decreased swelling, pain, and congestion from increased metabolism in the area of inflammation.
may be used later 24-48hours to promote healing by increasing the circulation to the inflamed site and sequent removal of drbis. Also used to localize the inflammatory agents. warm moist heat may help debride the wound site if necrotic material is present.
NSAIDS (ibuprofen- advil motrin)
Lower temperature by action on heat-regulating center in hypothalamus, resulting invasodilation and heat loss; interfere with release of PG's
• Good for FEVER and PAIN
• Not a good COX inhibitor in presence of ROS so NOT ANTI-INFLAMATORY
• SE: LIVER TOX: Small index of Toxic vs Therapeutic dose (4x)
•Lowers temperature by action on heat reg center in hypothalamus
affect hypothalamus & inhibit production of inflammatory mediators (PG's) at pain site
Conteract inflammation and swelling; corticosteroids and NSAIDs
1-Non-steroidal Antiinflammatory Drugs(NSAID)2-Steroidal Antiinflammatory Drugs e.g. Glucocorticoids (immunosuppressants)3-Drugs for Rheumatoid Arthritis(DMARD: Disease-Modifying Antirheumatic Drugs)4-Drugs for Gout 5-Antihistamines
-interfere with tissue granulation
- agents that decrease inflammation or itching
-Used medically as an anit-inflammatory agent
NSAIDs Ibuprofen, motrin
Inhibit synthesis of PG's
Process of healing, is the replacement of lost cells and tissues with cells of the same type.
Process of healing, cells being replaced by connective tissue
full thickness wound repair, surgical repair, edges are approximating, decreased risk of infection, involves little tissue loss, and heals with minimal scarring, EDGES of clean surgical wound remain closed together, heal quickly, minimal tissue loss
*topical antibmicrobials/antibactericidals ex. betadine, dakins sol, and chlorhexine, used with caution dont want to damage new tissue. Shoud not be used with clean granulated tissue.**
first phase of primary intention; lasts for 3-5 days; incision area fills with blood from the cut blood vessels, and blood clots form; this forms a provisional matrix for WBC migration; mesh work for healing is established during this phase for future capillary growth.
ground substances are produced followed by collagen formation; ground substances are deposited into the wound bed; collagen is then deposited as the wound undergoes the final phase of repair. Collagen is organized and restructured to strengthen the healing site. A scar is formed at this stage.
This is the final stage of (wound) healing. Begins about 7 days after the injury and may continue for up to 2 years. During this phase the scar tissue is remodeled. Scar tissue is weaker than the tissue it replaces. Contraction of the healing area brings the edges together, a mature scar is formed.
This type of healing is in wounds with extensive tissue loss & wounds in which the edges cannot be approximated (closed). Would is left open and granulation tissue gradually fills in the deficit. Susceptible to infection. Wet to dry dressings. Much larger scar. Ex: Pressure Ulcer
wound(debrie) may have to be cleaned away befor healing can take place.
a surgical wound (contaminated) left open until ready to close (suture), provides time to decrease edema or infection. aka delayed primary intention.
a wound that involves only the epidermis
full thickness wound
the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved
skin loss through the epidermis but not completely through the dermis. no dead tissue is present and no granualtion tissue (formation of collagen as it grows back).
Proliferation stage of healing, Developing granulation tissue, clean pink in appearance. GOAL: Protect
**gentle cleansing, re-epepithelilizing should be kept slightly moist. Transparent film or adhesive semipermeable dressing. ex. OpSite, Tegaderm, occlusive dresing that allow oxygen
- presence of slough or soft necrotic tissue
-Absorb drainage and remove nonviable tissue
absorptive dressing, hydrocolloidal dressing, hydrogel covered with gauze, wound irrigation, hydrotheraphy, moist gauze w/ or w/o antibiotic or antimicrobial agent
exudate: creamy ivory to yellow-green
Covered with thick necrotic tissue (eschar), may be brown, tan or gray in color.
-full thickness, 3rd* burns, pressure ulcer stage 3 or 4
- topical debridement, hydrotheraphy, moist gauze dressing, hydrogel covered with guaze, absorptive dressing covered with guaze
Factors effetcing wound healing
(vit c, protein, zinc)
Inad blood supply
corticosterroid drugs- impair phagocytosis by WBC's, depress formation of granulation tissue, inhibit wound contraction
Gauze and non wovens
can be used for cleansing, packing, and covering
may be used w/ saline, petrolattum, or antimicrobials. Are minimally absorbent, used mainly on minor wounds
semipermeable membrane that permits gaseous exchange between wound and environment; transparency allows visualization of the wound; minimally absorbent so fluid environment is created in presence of exudate; used for dry non infected wounds or wounds with minimal drainage
wafers, powders, or pastes composed of gelatin, pectin, or carboxymethylcellulose; occlusive dressing does not allow oxygen to diffuse from atmosphere to wound; does not interfere with wound healing. used for superficial and partial thickness, wounds w/ light to moderate drainage
Used for debridement
water or glycering based, soothing, reduce pain, rehydrate wound bed, facilitate autolytic debrideent, fill in dead space, minimally absroptive, secondary dressing is requirre (usually film) change every 1 to 3 days
pads/ribbons from seaweed. for heavy exudate
pro: packing exudating wounds, usable on infected wounds, high absorption
con: needs secondary dressing, too drying on low exudate, needs saline irrigation for gel removal
deliver agents that deliver agents such as iodine, silver, polyhexamethylene biguanide, have antibacterial properties. indicated in partial n full thickness wounds, over skin site and surgical incisions or around tracheostomies. available as sponges, gauze, film dresg, absorptive products, island drsg, nylon fabric, nonadherent barriers or combination of materials.
the partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate
wound separation with protrusion of organs
discomfort; uneasiness, a feeling at the beginning of an illness, a vague feeling of illness or depression
produces somewhat different reactions(swelling, redness, and local warmth may not be visible)
increased WBC count
with a shift to the left
increased pulse, resp rate, and fever
what test is used to determine positive diagnosis of SLE
ANA anti- nuclear antibodies
After an intradermal injection, the pt reports itching
apply a turniquet
a pt is receiving a penicillin injection (repeated dose) what should the nurse instruct the pt to do...
wait 20 minutes
hypnosis & imagery
affective and cognitive areas of pain
elevated BP, tachycardia, tachypnea
pt taking morphing, what should nurse anticipate
diminished bowel sounds, decreased respirations
side affects of spinal anesthesia
CD4 count and viral load for a pt diagnosed w/ HIV monitors what?
affectiveness of anti viral medication
Candida albicans associated w/ HIV
candidas in the mouth
anemia is a SE
shift to the left indicates
immature band neutrophils present
anything less than 25-30 cc's indicates renal failure
Skin ulceration caused by prolonged pressure, usually in a person who is bedridden; also known as decubitus ulcer or bedsore
heal by secondary intention
This type of healing is in wounds with extensive tissue loss & wounds in which the edges cannot be approximated (closed). Would is left open and granulation tissue gradually fills in the deficit. Susceptible to infection. Wet to dry dressings. Much larger scar.
a combination of friction and pressure which when applied to the skin results in damage to the blood vessels and tissues
risk factors for pressure ulcers
advanced age, anemia, contractures, diabetes, elevated body temperature, immobility, impaired circulation, incontinence, low diastolic blood pressure, mental deterioration, neurologic disorders, obesity, pain, prolonged surgery, vascular diseases,
stage one pressure ulcer
has intact with non blanchable redness of a small area of skin usually over a bony prominence. Area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.
stage two pressure ulcer
partial thickness loss of skin may look like an abrasion, blister, partial loss of dermis, with a red pink wound.
stage three pressure ulcer
Full-thickness skin loss involving damage or necrosis to subcutaneous fat may be visible but bone, tendon, and muscle are not exposed, may have tunneling.
stage four pressure ulcer
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures. Often include undermining and tunneling.
a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and eschar in the wound bed. Until removed/debrided this is the classification.
Nursing assessment of pressure ulcers
-in acute care, reassess pt q 24 hours
-long term care, reassess a resident weekly for the first 4 weeks, after admission, and then at least monthly or quarterly
-in home assess q visit
planning/ pressure ulcer
-have no deterioration of the pressure ulcer stage
-reduce or eliminate the factors that lead to pressure ulcers
-not develop an infection of the pressure ulver
-have healing of the pressure ulcer
-have no reaccurance
**Once a person has been identified at risk for a pressure ulcer... prevention remains the best treatment***
safety alert for pressure ulcers
-reposition frequently to prevent pressure ulcers
-use devices to reduce pressure and shearing force
ex: foam mattress, pressure mattress wheelchair cushions, padded commode seats
Pt's with dark skin
- look for changes in skin color, darker (purple, browner, bluish)
-use natural or a halogen light (fluorescent light cast a blue color)
-assess area of skin temperature
-touch skin to feel consistancy
-ask the pt if they are in pain or feel any itching
nursing assessment for pressure ulcers
see page 201, lazy... in lewis
assess risk for pressure ulcers scale from 1-4. Under 16 is high risk (18 for dark skin). sensory perception, moisture, activity, mobility, nutrition, friction/shear
acute intervention for pressure ulcer
need support measure of the whole person: adequate nutrition, pain mgmt, control of other medical conditions, and pressure relief.
local care of pressure ulcer
may invole debridement, wound cleaning, application of a dressing, and relief of pressure.
pressure ulcer w/ necrotic tissue or eschar
must have the tissue removed by surgical, mechanical, enzymatic, or autolytic debridement.
****except for dry, stable necrotic feet or heels***
pressure ulcer cleaning
should be cleaned w/ noncytotoxic solution that do not kill or damage the cells, esp fiberblast.
***do not useDakins solution, acetic acid,providone-iodine or hydrogen peroxide, they are cytotoxic***
irrigation of pressure ulcers
use enough pressure to adequately clean the wound w/o causing trauma or damage to the wound, to obtain this pressure use a 30ml syringe and a 19g needle.
after pressure ulcer has been cleansed
cover slightly moist,rather than dry, to enhance re-epithelialization.
** a wet/dry dressing should never be used on a granulating pressure ulcer; this type of dressing should only be used for mechanical debridement of the wound****
stage 2-4 pressure ulcers
are considered to be contaminated or colonized with bacteria, remember to watch for signs of of infection:
elevated WBC count
***may not be present even though the ulcer is infected****
clinically sig mal nutrition-p/ulcer
serum albumin is less than 3.0 g/dl
total lymph count is less than 1800/ul
or body weight decreases by more than 15%
caloric intake needed to correct mal nutrition
30-35 calories/kg/day and 1.25-1.50 of protien/kg/day
if needed parental nutrition of amino acids and glucose solutions are used