Inflammatory response
Dilutes the inflammatory agent, removes necrotic materials, and establishes and environment suitable for healing and repair
What is the inflammatory response?
Increased killing of microorganisms, increased phagocytosis by neutrophils, and increased proliferation of T cells are all beneficial aspects of this
What is a fever?
These are all complications of wound healing
What are adhesions, contractions, dehiscence, evisceration, excess granulation tissue "proud flesh", fistula formation, infection, hemorrhage, hypertrophic scars, keloid formation
Advanced age, anemia, contractures, critically ill or cared for in a critical care setting, diabetes, fever, friction, hip fracture, immobility, incontinence, long and/or extensive surgical procedure, low diastolic blood pressure, major trauma, mental deterioration, neurological disorders, pain, peripheral vascular disease, spinal cord injury
Care plans for infection
Hyperthermia related to increased metabolic rate
Ineffective protection related to inadequate nutrition, abnormal blood profiles, drug therapies, treatments
Impaired social interaction related to therapeutic isolation
Risk for vascular trauma: risk factor: infusion of antibiotics
Risk for infection
These are responsible for the redness, swelling, and heat at the site of injury and the surrounding area
What are vasodilation and increased capillary permeability?
There is a __% increase in metabolism for every 1* F increase in temperature above 100F, or a 13% increase for every 1* C
7
Advanced age, anemia, corticosteroid drugs, diabetes, inadequate blood supply, infection, mechanical friction on wound, nutritional deficiencies, obesity, poor general health, smoking
What are factors that may delay wound healing?
Staging of a pressure injury is based on this
What is the visible or palpable tissue in the injury bed?
Care plans for fever
Ineffective thermoregulation related to infectious process
Risk for imbalanced body temperature: risk factors: acute brain injury, pharmaceutical agent
Match the definitions with the white blood cells:
Monocytes, neutrophils, lymphocytes
The first WBCs to arrive at the injury site, they phagocytize bacteria, other foreign material, and damaged cells. The accumulation of dead these, combined with digested bacteria, and other cell debris creates pus.
The second type of phagocytic cells, they arrive within 3-7 days of inflammation. These transform into macrophages. Macrophages are important in cleaning the area before healing. When particles are too large for a single macrophage, they accumulate to form a multinucleated giant cell (TB).
These arrive later at the site of the injury. They aid in humoral and cell-mediated immunity.
First: neutrophils
Second: monocytes
Third: lymphocytes
These patients are the ones for whom antipyretics are vital
What are the very young or very old, extremely uncomfortable, or significant medical problem patients. Fever in the immunocompromised patient should be treated immediately with antibiotics because infections can rapidly progress to septicemia.
"Airing out" a wound is a good means of speeding wound healing: true or false?
False. Dryness is an enemy of wound healing.
Repositioning the patient and these devices are used to reduce pressure and shear
What are low-air-loss mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots (foam, air), lift sheets?
Care plans for wound infection
Disturbed body image related to open wound
Imbalanced nutrition: less than body requirements related to biological factors, infection, fever
Ineffective thermoregulation r/t infection in wound resulting in fever
Impaired tissue integrity r/t wound, presence of infection
Risk for imbalanced fluid volume: risk factor: increased metabolic rate
Risk for infection: spread of: risk factor: imbalanced nutrition: less than body requirements
Risk for delayed surgical recovery: risk factor: presence of infection
These cells are important in causing fever and other manifestations of inflammation. An increase in pulse and respiration follows the rise in metabolism due to fever.
What are cytokines (e.g. interleukins, tumor necrosis factor [TNF])?
Match the medication to their mechanism of action:
(A) Corticosteroids
(B) NSAIDs (ibuprofen)
(C) aspirin
(D) acetaminophen
(1) Blocks PG synthesis in the hypothalamus and elsewhere in the brain
(2) Acts on the heat-regulating center in the hypothalamus
(3) Have antipyretic effects
(4) Antipyretic through the dual actions of preventing cytokine production and PG synthesis- results in dilation of superficial blood vessels, increased skin temp, and sweating
1: C
2: D
3: B
4: A
Debridement of a wound or use of absorptive dressings may be needed for this type of wound
What are contaminated wounds?
These factors lead to the development of pressure injuries, and should be considered when preventing harm
What are amount of pressure (intensity), length of time the pressure is exerted on the skin (duration), and ability of the patient's tissue to tolerate the externally applied pressure. Other factors include shear (pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement [i.e. pulling the patient up in bed]), and excessive moisture (increases risk for skin breakdown).
Care plans for pressure ulcer
Impaired bed mobility r/t intolerance to activity, pain, cognitive impairement, depression, severe anxiety, severity of illness
Imbalanced nutrition: less than body requirements r/t limited access to food, inability to absorb nutrients because of biological factors, anorexia
Acute pain r/t tissue destruction, exposure of nerves
Impaired skin integrity: state I or II pressure ulcer r/t physical immobility, mechanical factors, altered circulation, skin irritants, excessive moisture
Impaired skin integrity: stage III or IV pressure ulcer r/t altered circulation, impaired physical mobility, excessive moisture
Risk for infection: risk factors: physical immobility, mechanical factors (shearing forces, pressure, restraint, altered circulation, skin irritants, excessive moisture, open wound)
Risk for pressure ulcer
The synthesis of these is the most critical metabolic change
What are prostaglandins?
This is a key concept in treating soft tissue injuries and related inflammation
What is RICE?
Rest helps the body use nutrients and O2 for healing process
Cold is appropriate at time of initial trauma as it promotes vasoconstriction and decreases swelling, pain, and congestion from increased metabolism in the area of inflammation. Heat may promote healing by increasing inflammation to the inflamed site and subsequent removal of debris. Heat is used to localize the inflammatory agents.
Compression and immobilization: counters the vasodilation effects and development of edema. Assess distal pulses before and after application of compression to evaluate whether compression has compromised circulation. Immobilization promotes healing by decreasing metabolic needs, prevents further tissue injury from sharp bone fragments
Elevation reduces edema at the inflammatory site by increasing venous and lymphatic return.
Match the phase with the duration and description
(A) Initial (B) Granulation (C) Maturation and scar contraction
(1) 5 days to 4 weeks; migration of fibroblasts, secretion of collagen, abundance of capillary buds, wound fragile
(2) 3 to 5 days; approximation of incision edges, migration of epithelial cells, clot serving as meshwork for starting capillary growth
(3) 7 days to several months; Remodeling of collagen, strengthening of scar
1: B
2: A
3: C
These are the complications of pressure injuries
What are infection, cellulitis (spreading of inflammation to subcutaneous or connective tissue), chronic infection, sepsis, and possibly death. The most common complication is recurrence; therefore it is important to note the location of previously healed pressure injuries on a patient's admission assessment.