Types & Manifestations of Inflammation
Healing that occurs over weeks to year
Provide an example
What is chronic inflammation?
Examples include: osteomyelitis or rheumatoid arthritis
This portion of healing deals with the edges of the incision are aligned and the acute inflammatory process begins.
What is primary intention?
Nutritional deficiencies
What is risk factor?
Examples: Vitamin C, Protein, Zinc
It has non-blanchable erythema of intact skin
Changes in sensation, temperature, or firmness, can precede visual changes
What is Stage 1?
How often do we perform repositioning on a patient?
What is every 2 hours?
Items we can use to help with support of repositioning includes low air-loss mattress, foam mattress, wheelchair cushions, padded commode seats, air/foam boots, and lift sheets.
Healing that occurs over 2-3 weeks
Provide an example
What is acute inflammation?
Examples include: allergic reaction, appendicitis, anaphylaxis
This stage of healing has wide, ireegular margins which contains more debris, cells and exudate. This is where a wound will need to be debrided.
Healing occurs from the edges in and from the bottom up
What is secondary intention?
Chronic infection
This leads to the body not being able to recover from the microbes
Full thickness skin loss
Subcutaneous and adipose tissue are visible
(no bone, tendon, or muscle)
Slough can be present
May have undermining
What is Stage 3?
Nutritional therapy for patients with wounds includes a diet high in
What is protein, carbohydrates, and moderate amount of fat?
Signs of local inflammation
Local inflammation includes: redness, heat, pain, swelling, and loss of function
This stage of healing occurs due to delayed suturing of the wound. The wound is either contaminated and left open or has to be reopened due to infection. It leaves a larger, deeper scar.
What is tertiary intention?
Inadequate blood supply
What is risk factor?
This is due to decreasing nutrient supply.
Partial thickness loss of skin with exposed dermis
Shallow, moist, and open with a red-pink wound bed
Presents as either intact or ruptured serum filled or serosanguineous fluid blister
What is Stage 2?
Nurses inform patient to manage three important pieces about onself's while at home
What is rest, hydration, and nutrition?
Wound healing can take upwards to 4-6 weeks or longer
Signs of chronic inflammation
Chronic inflammation clinical manifestations include fatigue (malaise), nausea (anorexia), increased HR and RR, fever, and increased shift from WBC from shift to the left
Similar to primary, but with the gaping wound edges
What is secondary intention?
Cellulitis
What is complication?
This leads to a spreading of inflammation to the subcutaneous or connective tissue.
Full thickness loss with shown muscle, bone, tendon
These are exposed, palpable or involved
May have slough or eschar
Can have undermining or tunneling
What is Stage 4?
Patients with wounds need a diet high in which vitamins
Vitamins A, B complex and C
When do we become concerned with fever?
What is 103 degrees Fahrenheit?
But Why oh Why?
Fever causes our body to increase heat production and reaches a new point (think of like when you set your thermostat in the car or heater). The body becomes hot and then causes chills to raise the warmth to reach new point.
Fever kills microorganisms, increases the engulfing of bacteria by the neutrophils.
What healing process deals with the wound being reopened?
What is tertiary intention?
Death
What is a complication?
This is due to severe sepsis that the body isn't able to recover.
Full thickness skin and tissue loss, extent is not able to be shown due to obscured by slough or eschar
Slough or eschar have to be removed to expose base of wound and determine depth
What is unstageable?
Nurses rotate a swab near the center of the wound using enough pressure to extract fluid from deep tissue layers of wound.
What is this describing?
What is a culture swab?
Remember: Don't provide necrotic tissue or exudate on the sample, because it doesn't provide an accurate sample.