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Inflammatory Response
- Causes
- - Heat
- - Radiation
- - Trauma
- - Allergens
- - Infection
- Intensity of the response depends on
- - Extent and severity of injury
- - Reactive capacity of injured person
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Vascular response
- - After initial vasoconstriction, vessels dilate bringing more blood to area
- - Fibrin released to begin clotting cascade
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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
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Local response to inflammation
- - Redness
- - Heat
- - Pain
- - Swelling
- - Loss of function
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Systemic response to inflammation
- - Increased WBC count with a shift to the left
- - Malaise
- - Nausea and anorexia
- - Increased pulse and respiratory rate
- - Fever
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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
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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
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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
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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
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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
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Wound management goals
- Clean wound to remove debris
- Treat infection
- Protect wound to promote healing
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Suture care
- Keep clean, monitor intactness, S&S of infection
- Itching normal sign of healing, not infection
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Primary intentions wounds
Usually just need DSD or transparent bandage spray
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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
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Nutritional Therapy
- Incr. Fluid intake
- Diet high in
- - Protein
- - Carbs
- - Vitamins- esp. Vitamin C & complex
- May require:
- Oral supplements- Ensure
- Parenteral nutrition (TPN)
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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
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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
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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
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Stage II
- ¨Partial thickness loss of epidermis, dermis, or both
- ¨Presents as an abrasion, intact or ruptured blister, or shallow crater
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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
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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
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Infection
- Leukocytosis
- Fever
- Increased ulcer size, odor, or drainage
- Pain
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Complications
- Most common—recurrence
- Cellulitis
- Chronic infection
- Osteomyelitis
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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
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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
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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!
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¨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
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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
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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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