Med Surg Test 1 Review (inflammation)

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FeverRN
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23818
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Med Surg Test 1 Review (inflammation)
Updated:
2010-06-16 18:11:31
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med surg test one inflammation wounds pressure ulcers
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Med Surg Test 1 Review (inflammation)
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  1. Inflammatory Response
    • Causes
    • - Heat
    • - Radiation
    • - Trauma
    • - Allergens
    • - Infection

    • Intensity of the response depends on
    • - Extent and severity of injury
    • - Reactive capacity of injured person
  2. Vascular response
    • - After initial vasoconstriction, vessels dilate bringing more blood to area
    • - Fibrin released to begin clotting cascade
  3. Cellular response
    • —Neutrophils
    • —- Work to phagocytize bacteria
    • —- “shift to the left”= inc. band (immature) neutrophils indicating acute bacteria infection

    • —Monocytes
    • —- Phagocytosis of inflamed debris

    • —Basophils
    • —- Release histamine and heparin

    • —Eosinophils
    • —- Released during allergic reaction; regulate histamine
  4. Local response to inflammation
    • - Redness
    • - Heat
    • - Pain
    • - Swelling
    • - Loss of function
  5. Systemic response to inflammation
    • - Increased WBC count with a shift to the left
    • - Malaise
    • - Nausea and anorexia
    • - Increased pulse and respiratory rate
    • - Fever
  6. Regeneration
    • =replacement of lost cells with new (same) cells
    • Constantly dividing cells that rapidly regenerate (labile)
    • ­Skin, bone marrow, lymphoid organs, as well as mucous membrane cells of the urinary, reproductive, and GI tracts
    • Permanent cells such as neurons, skeletal and cardiac muscle do not divide
    • ­Neurons are replaced by glial cells, and new neurons may be produced by stem cells
    • ­Skeletal and cardiac muscle will be repaired with scar tissue
  7. Repair
    • Primary intention= wound margins neatly approximated
    • Initial phase (3-5 days)
    • Granulation phase= surface begins to regenerate
    • Maturation phase and scar contraction

    Secondary intention = irregular wound edges

    Tertiary intention= wound generally left open 2ndary to infection
  8. Wound classifications
    • By cause
    • ie- Surgical vs. non-surgical

    • By tissue depth
    • Superficial = only epidermis
    • Partial thickness = into dermis
    • Full thickness = into subQ or deeper

    • By color – only used with secondary intention (see text)
    • Red
    • Yellow
    • Black
  9. Complications of healing
    • Keloid formation
    • Created from excess collagen tissue

    • Contracture
    • = excessive shortening of muscle or scar tissue

    • Adhesions
    • =internal scar tissue bands
    • Can lead to obstructions, pain, etc.

    • Dehiscence
    • =separation of previously joined skin edges

    • Evisceration
    • Internal organs protrude
  10. Nursing Management Inflammation (no open wound)
    • Acute intervention
    • Observation and vital signs
    • ­Fever
    • - Identify the cause
    • - Tx with ASA or NSAIDs

    • RICE
    • ­- Rest
    • ­- Cold and heat
    • COLD 1ST 24 HRS, THEN HEAT
    • ­- Compression & immobilization
    • splint, ace bandage, etc
    • ­- Elevation- to decr. edema
  11. Wound management goals
    • Clean wound to remove debris
    • Treat infection
    • Protect wound to promote healing
  12. Suture care
    • Keep clean, monitor intactness, S&S of infection
    • Itching normal sign of healing, not infection
  13. Primary intentions wounds
    Usually just need DSD or transparent bandage spray
  14. Secondary intention
    • usually needs debridement (removal of dead, damaged, or infected tissue to improve healing of healthy tissue)
    • - Red wound
    • - Yellow wound
    • - Black wound

    • —Red wound
    • —- Keep clean & moist
    • —- Opsite, Tegaderm

    • —Yellow wound
    • —- Need to remove necrotic tissue & absorb drainage
    • —- Absorption dressings (hydrogel)
    • —- Hydrocolloid (duoderm)

    • —Black wound
    • —- Requires debridement
    • Surgical
    • Mechanical (wet-to-dry dressings or irrigations)
    • Autolytic
    • Enzymatic
  15. Nutritional Therapy
    • Incr. Fluid intake
    • Diet high in
    • - Protein
    • - Carbs
    • - Vitamins- esp. Vitamin C & complex
    • May require:
    • Oral supplements- Ensure
    • Parenteral nutrition (TPN)
  16. Infection prevention and control
    • - Aseptic technique (except with decubiti)
    • - Prophylactic antibiotics (for some clients)
    • - Tx each wound as separate wound (don’t cross-contaminate)


    • Psychologic implications
    • - Fear of wound, odor, being rejected by others

    • Client/family teaching
    • - Wound care with return demos
    • - S&S of infection & complications
  17. Pressure Ulcer Risk Factors
    • ¨Advanced age
    • ¨Anemia
    • ¨Contractures
    • ¨Diabetes mellitus
    • ¨Elevated body temperature
    • ¨ Immobility
    • ¨Impaired circulation

    • ¨Incontinence
    • ¨Low diastolic blood pressure (<60 mm Hg)
    • ¨Mental deterioration
    • ¨Neurologic disorders
    • ¨Obesity
    • ¨Pain
    • ¨Prolonged surgery
    • ¨Vascular disease
  18. Stage I
    • ¨Observable pressure-related alteration of intact skin
    • ¨Possible indicators—skin temperature, tissue consistency, poor sensation
    • ¨Ulcer appears as persistent redness in lightly pigmented skin
    • ¨May appear with red, blue, or purple hues in darker skin tones
  19. Stage II
    • ¨Partial thickness loss of epidermis, dermis, or both
    • ¨Presents as an abrasion, intact or ruptured blister, or shallow crater
  20. Stage III
    • ¨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
  21. Stage IV
    • ¨Full-thickness loss can extend to muscle, bone, or supporting structures
    • - Bone, tendon, or muscle may be visible or palpable
    • - Undermining and sinus tracts may also exist
  22. Infection
    • Leukocytosis
    • Fever
    • Increased ulcer size, odor, or drainage
    • Pain
  23. Complications
    • Most common—recurrence
    • Cellulitis
    • Chronic infection
    • Osteomyelitis
  24. Assessment
    • Assess pressure ulcer risk on admission & at periodic intervals
    • Use risk assessment tools such as Braden scale for systematic skin inspection
    • - At least BID
  25. Assessment-clients with dark skin
    • Look for areas of skin darker (purplish, brownish, bluish) than surrounding skin
    • Use natural or halogen light for accurate assessment (fluorescents can skew results)
    • Assess skin temperature using hand
    • - ulceration may feel initially warm, then become cooler
    • Touch skin to feel consistency
    • - Boggy or edematous tissue may indicate a Stage I pressure ulcer
    • Ask about pain or an itchy sensation
  26. Prevention–Education
    Prevention is the best treatment

    • Identify risk factors and specific clients at risk
    • - and implement prevention strategies
    • - Implement foam mattresses, cushions, padded boots, etc.

    MOBILIZATION is best offense!
  27. Prevention–Skin Care
  28. ¨Remove excessive moisture
    • ¨Avoid massage over bony prominences
    • ¨Turn q 1-2 hrs (avoid shearing)
    • ¨Use lift sheets
    • ¨Position with pillows or elbow & heel protectors
    • ¨Use specialty beds
    • ¨Cleanse & dry skin if incontinence occurs
  29. Prevention–Nutrition
    • Caloric intake elevated to 30 to 35 cal/kg/day or 1.25 to 1.50 g protein/kg/day
    • - Supplements, enteral, or parenteral feedings may be necessary
  30. Treatment–Ulcer Care
    • ¨Keep ulcer bed moist
    • - Don’t allow to dry out
    • ¨Cleanse with nontoxic solutions
    • - No betadine, peroxide, etc.
    • ¨Debride
    • - Gets rid of necrotic tissue
    • ¨Use adhesive membrane, ointment, or wound dressing

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