Med Surg Test 1 Review (inflammation)

• Causes
• - Heat
• - Radiation
• - Trauma
• - Allergens
• - Infection

• Intensity of the response depends on
• - Extent and severity of injury
• - Reactive capacity of injured person

• - After initial vasoconstriction, vessels dilate bringing more blood to area
• - Fibrin released to begin clotting cascade

• —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

• - Redness
• - Heat
• - Pain
• - Swelling
• - Loss of function

• - Increased WBC count with a shift to the left
• - Malaise
• - Nausea and anorexia
• - Increased pulse and respiratory rate
• - Fever

• =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

• 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

• 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

• 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

• 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

• Clean wound to remove debris
• Treat infection
• Protect wound to promote healing

• Keep clean, monitor intactness, S&S of infection
• Itching normal sign of healing, not infection

Usually just need DSD or transparent bandage spray

• 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

• Incr. Fluid intake
• Diet high in
• - Protein
• - Carbs
• - Vitamins- esp. Vitamin C & complex
• May require:
• Oral supplements- Ensure
• Parenteral nutrition (TPN)

• - 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

• ¨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

• ¨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

• ¨Partial thickness loss of epidermis, dermis, or both
• ¨Presents as an abrasion, intact or ruptured blister, or shallow crater

• ¨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

• ¨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

• Leukocytosis
• Fever
• Increased ulcer size, odor, or drainage
• Pain

• Most common—recurrence
• Cellulitis
• Chronic infection
• Osteomyelitis

• Assess pressure ulcer risk on admission & at periodic intervals
• Use risk assessment tools such as Braden scale for systematic skin inspection
• - At least BID

• 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

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!

• ¨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

• 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

• ¨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