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Unit 4: Cellular, inflammation, Infection, and wound healing

Complement System

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

redess (rubor)
heat (calor)
pain (dolor)
swelling (tumor)
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

Purulent

producing or containing pus

Serous

Results from outpouring of fluid: early stages of inflammation or when injury is mild

Serous- guineous

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.

Fibrinous

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.

Acute inflammation

inflammation of less than two weeks duration often associated with bacterial infections and usually characterized by the presence of neutrophils, monocytes, and macrophages

Subacute Inflammation

healing lasts longer than 2-3 weeks, but usually leaves no residual damage. ex. infective endocarditis

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?

Fever

a rise of body temperature above the normal. It is caused by cytokines produced in response to infection.

Chronic inflammation

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

ACUTE INTERVENTION:
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)
HIGH TEMPERATURE
HIGH PULSE
HIGH RESPIRATIONS

Fever

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

Fever

Pt very young, very old, extremely uncomfortable or has a significant med problem. THE USE OF ANTIPYRETICS SHOULD BE CONSIDERED.

Fever

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.

Antypyretics

Should be given round the clock to prevent acute swings in skin temp/ admin in 2-4 hr intervals

COLD

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.

HEAT

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.

Antipyretic drugs

salicylates (aspirin)
aceptaminophen (tylenol)
NSAIDS (ibuprofen- advil motrin)

Antipyretic drugs

Lower temperature by action on heat-regulating center in hypothalamus, resulting invasodilation and heat loss; interfere with release of PG's

Acetaminophen (tylenol)

• 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

NSAID's

affect hypothalamus & inhibit production of inflammatory mediators (PG's) at pain site

IBUPROFEN,( MOTRIN)
PIROXICAM,(FELDENE)

Antiinflammatory drugs

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

Corticosteroids

-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

Regeneration

Process of healing, is the replacement of lost cells and tissues with cells of the same type.

Repair

Process of healing, cells being replaced by connective tissue

primary intention

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.**

initial phase

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.

granulation phase

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.

maturation phase

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.

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. Ex: Pressure Ulcer
wound(debrie) may have to be cleaned away befor healing can take place.

Tertiary Intention

a surgical wound (contaminated) left open until ready to close (suture), provides time to decrease edema or infection. aka delayed primary intention.

superficial wound

a wound that involves only the epidermis

full thickness wound

the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved

partial thickness

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).

red wound

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

yellow wound

- presence of slough or soft necrotic tissue
-Absorb drainage and remove nonviable tissue
ex. DuoDerm
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

black wound

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

Nutritional def
(vit c, protein, zinc)
Inad blood supply
corticosterroid drugs- impair phagocytosis by WBC's, depress formation of granulation tissue, inhibit wound contraction
infection
smoking

Gauze and non wovens

can be used for cleansing, packing, and covering

nonadhearent dressings

may be used w/ saline, petrolattum, or antimicrobials. Are minimally absorbent, used mainly on minor wounds

Transparent films

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

Hydrocolloids

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

hydrogel

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

aliginates

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

antimicrobials dressings

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.

dehiscence

the partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate

evisceration

wound separation with protrusion of organs

maliase

discomfort; uneasiness, a feeling at the beginning of an illness, a vague feeling of illness or depression

systemic inflammation

produces somewhat different reactions(swelling, redness, and local warmth may not be visible)
increased WBC count
with a shift to the left
malaise
nausea
anorexia
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

acute pain

elevated BP, tachycardia, tachypnea

pt taking morphing, what should nurse anticipate

diminished bowel sounds, decreased respirations

side affects of spinal anesthesia

urinary retention
spinal headache

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

AZT

anemia is a SE

shift to the left indicates

immature band neutrophils present

renal

anything less than 25-30 cc's indicates renal failure

pressure ulcer

Skin ulceration caused by prolonged pressure, usually in a person who is bedridden; also known as decubitus ulcer or bedsore

pressure ulcers

heal by secondary intention

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.

shearing force

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.

unstageable ulcer

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

braden scale

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:
purulent exudate
odor
erythema
warmth
tenderness
edema
pain
fever
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

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