Chapter 13-Infection & Wound Healing
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| What is inflammatory response and what is the goal? | Reaction to cell injury. Goal: remove necrotic debris and make suitable for healing
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| What is an infection? | Organism-bacteria, protozoa, fungus--invades tissues
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| What is intensity of response? | The degree of response depends on degree of injury; immune suppression decreased = decreased response
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| Types of inflammatory response systems? | Vascular Response & Cellular Response
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| Vascular Response (what the arteries will do?) | Arteries initially dilate, to allow chemoreceptors into area=redness & warmth
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| Cellular Response (what do the different cells do?)Neutrophils | Neutrophils: 1st line of defense, immature WBC "shift to the left", arrive in 6-12 hours, only around 24-48 hrs. Puss=accumulation of dead neurtrophils
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| Cellular Response (what do the different cells do?)Monocytes | 2nd WBC to arrive, arrive in 3-7 days, transform into macrophages to eat debris
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| Lymphocytes | 3rd WBC to arrive, involved in humoral and cell-mediated immunity--how vaccines work
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| Chemical Mediators: Complement System, Protaglandins, Leukotrienes | Complement system: chemical reaction, multiple enzymes react in sequence that cause more inflammation to occur. Get appropriate cells to area to clean it out and allow healing to occur
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| Prostaglandins | Produced by injured cells; cause vasodilation and sensitive pain receptors (why we hurt)
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| Leukotrienes | active in anaphylactic reaction, cause smooth muscle contraction of bronchi, increase capillary permeability--get bronchial restriction and pulmonary edema
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| Clinical manifestations: 1) local response, 2) systemic response, 3)Fever | local response: redness, pain, swelling
systemic: incr WBC, fever, malaise
Fever: triggered by protaglandins & cytokines; response to chem agts being sent out; incr temp creates a "bad" envir; treat fever >101.5; lower fever part of immune resp
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| Inflammation | Acute: comes on & resolves in 2-3 wks; temp, no long damage
Chronic: weeks to months to yrs; Lupus pts, RA pts
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| Nursing Management: vitals, fever, meds, RICE | Sympts of inflam response: initial bp incr, systemic sepsis decrease bp; temp incr,hr incr, RR incr
Fever: not damaging until >104; treat for comf., 105.8=brain damage; "rate" of incline-rapid incrs=seizures
Meds:tylenol, ibuprofen, aspirin
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| Two types of healing: regeneration & repair | Regeneration: replacement of lost or damaged cells w/same cell type
Repair: replacement of damaged cells w/ connective tissue-leads to scar tissue
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| Primary repair-wound edges well approximated (i.e. surgical incision) | Primary Repair:
Initial-neutrophils, platelets form clots,meshwork
Granulation-start of new tissue; bright red
Fibroblasts-immature connective tissue cells; secrete collegen and form scar tissue
Maturation&scar-can last 7 days to years
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| Secondary repair-wound is open | healing from sides in & bottom up; must keep wound bed clean
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| Tertiary repair-delayed primary repair | wound too swollen to close, surgically come back to put together
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| Complications of scars | Hypertrophic Scars & Keloids
Contracture
Dehiscence
Excess granulation tissue
Adhesions
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| Hypertrophic Scars & Keloids | Hypertrophic: over abundance of collegen--red-raised scars, excessive scar formation
Keloids: protusion of scar tissue; huge over growth, expands beyond boundary of wound; pt. may complain of pain & tenderness,hereditary, more common in dark skin people
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| Contracture | Connective tissue doesn't skin to expand; burns of injuries over joints--must keep moving to keep mobility, always have in functional position
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| Dehiscence | wound opens
Risk factors: infection, diabetes, obesity, too much pressure on wound/surgical site (split w/pillow)
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| Excess granulation tissue | "proud flesh" granulation tissue that protrudes above surface of wound--surgically removable, will not grow back
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| Adhesions | most common area=abdominal cavity; attaches to greater omentum & organs
Scar tissue in abd cavity, can cause small bowel obstruction
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| Wounds: need to make note of closure device | sutures (7-10 days), staples (head, abdomen, hips), glue (open heart), retention sutures (trying to bring edges together)
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| Wound colors | Red: Good!!granulation tissue, pink, a little bleeding, wet wound
Yellow: needs to be debrided for wound to heal; wet-to-dry & pack to pull of slough
Black: eschar tissue, surgically removed, debride in order for healing to occur
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| nutrition management | high protein, high calorie, Vit. A,B,C,D
NG tube first option for feeding--want to use "gut" first; TPN next
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| Infection prevention | use cleanest technique possible (aseptic tech,) watch MD order
Culture-ID microorganism (ideal before 1st dose of antibiotic)
Sensitivity-IDs most effective antibiotic
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| Patient teaching | note change in drainage, wound color, adequate rest, good nutrition
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| What causes Pressure Ulcers? | Pressure, friction, sheering forces, moisture, length on side
*pressure ulcers heal by secondary intention; significant PU can take months to years to heal
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| How many Stages of PUs? | Suspected deep tissue injury, Stages I-IV & unstagable
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| Suspected Deep Tissue injury | purple of maroon localized are of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or sheer. Area may be preceded by tissue that is painful, firm, mushy, boggy, warm or cool as compared to adj tissue
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| Stage I | intact skin w/nonblanchable redness of local area usually over bony prominence. Area may be painful, firm, soft, warm or cooler than adjac. skin
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| Stage II | partial-thickness loss of dermis manifesting as a shallow, open ulcer with a red-pink wound bed w/out slough. May look like serum-filled blister
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| Stage III | full-thickness tissue loss. subcut fat may be visible, but bone, tendon and muscle are not exposed. Slough may be present. May include undermining and tunneling
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| Stage IV | full-thickness tissue loss w/exposed bone, tendon or muscle. Slough and eschar may be present. Often includes undermining and tunneling
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| Unstageable | full-thickness tissue loss in which base of ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar in the wound bed
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