Medical surgical nursing-chapter 13 test questions and answers.

define: a sequential reaction to cell injury alizes and dilutes the inflammatory agent 2. removes necrotic material 3. establishes an environment suitable for healing and repair. inflammatory response define: 3 mmation is ALWAYS present with infection 2. infection is NOT always present with inflammation 3. can because by heat, radiation, trauma, chemical agents, allergens and autoimmune reaction. inflammation facts 3 Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:00 Full screen 1. invasion of tissue or cells by microorganisms such as bacteria, fungi, and viruses. inflammation involves: 1 1. vasoconstriction 2. release of histamine/chemicals by injured cell 3. local vasodilation (resulting in increased blood flow, thus raising filtration pressure) 4. increased capillary permeability, local edema (redness, heat, swelling) 5. inflammatory exudate ( fluid exudate/ cell exudate) 6. fribinogen and leaves the blood, activates fibrin, fibrin strengthens blood clot forms platelets. 7. platelets release growth factor, healing starts. vascular response process: 7 chemotaxis definition: the directional migration of white blood cells to a site of injury. cell response 1. chemotaxis 2. neutrophils are the first leukocyte to arrive(6-12hrs). a. phagocyte engulf bacteria, foreign material and damaged cells. b.(24-48hrs) dead neutrophils accumulate. pus occurs. 3. bone marrow releases more neutrophils into circulation, resulting in elevated WBC's. 4.(3-7days) monocyte arrive. entering the tissue space, monocytes transform to microphages. b. macrophage role is to assist in phagocytosis of the inflammatory debris. (essentially cleaning the area so the healing process can occur) 5. lymphocytes arrived later. a. their role is related to hormonal and cell mediated immunity 6. inflammatory exudate(fluid exudate/cell exudate) bands immature forms of neutrophils shift to the left finding increase number of band neutrophils in circulation.(often found with acute bacterial infections) local response: inflammation includes the manifestation of redness, heat ,pain, swelling, and loss of function. systemic response: manifestations of inflammation include an increased WBC count with a shift to left, nausea, anorexia,increased pulse and respiratory rate fever malaise. clinical manifestations: inflammation 1. Serous: watery and clear -> skin blisters and wound drainage 2. purulent: yellow or green opaque discharge-> wound infection, sputum, cellulitis 3. hemorrhagic: presence of rbc's-> Bloody drainage, Hemorrhage from Wound site 4. serosanguineous: clear drainage with a little blood-> drainage from Jackson - Pratt and Penrose drains. types of exudate: 4 histamine stored granules and basiphils, mast cells, platelets MOA-causes vasodilation and increased capillary permeability prostaglandins and leukotrienes produce from arachidonic acid MOA- PG's cause vasodilation, LT's stimulate chemotaxis 1. triggered by the release of cytokines 2. cytokines initiate metabolic change in the temperature regulating center of the hypothalamus 3. step 1&2 activate the body's defense mechanisms. 4. beneficial aspects of fever include: increased killing of microorganisms, increased phagocytosis by neutrophils, and increased proliferation of T cells. fever facts: 4 1. acute inflammation-healing occurs in 2 - 3 weeks usually leaves no residual damage. ex. paper cut 2. sub- acute inflammation -has the features of acute process but last longer (wks-months) ex. endocarditis 3. chronic inflammation-last weeks, months, or even years. ex. rheumatoid arthritis/osteomyelitis types of inflammation: 3 Rest, ice, compression, and elevation. 1. key concept and threatening soft tissue injuries and related inflammation. rest: help the body use its nutrients and oxygen for the healing process ice: (Cold and heat) application causes vasoconstriction and decrease swelling and pain. compression: (compression and immobilization) counters vasodilation effects and development of edema. that includes blood vessel in stops bleeding. compression bandages provide support (assess distal pulses and capillary refill before application of compression bandage) elevation: reduces edema and increases venous an lymphatic return and reduces pain. ( maybe contraindicated in patients with significant reduced arterial circulation) RICE therapy define: the replacement of lost cells in tissue with cells of the same type eration of cells depends on the cell type. a. labile cells divide constantly. ex. cells of the skin, lymphoid organs, bone marrow, and mucous membranes of the gastrointestinal tract, urinary and reproductive tracts. b. stable cells retained their ability to regenerate but do so only if the organ are injured. ex. liver, pancreas, kidney, and bone cells. c. permanent cells do not divide. ex. neurons of the central nervous system, skeletal and cardiac muscles. regeneration define: healing as a result of lost cells being replaced by connective tissue. injuries heal by connective tissue repair. repair healing takes place when wound margins are nearly approximated, as any surgical incision or a paper cut. phases of repair: primary intention s that occur from trauma ulceration, and infection have large amounts of exudate and why the regular wound margins with extensive tissue loss. 2. these wounds have edges that cannot be approximated. 3. debriment may have to be performed before healing can take place. 4. wound heals from the bottom of the wound upward until the defect is filled. phases of repair : secondary intention 4 healing occurs with delayed suturing of a wound, in which two layers of granulation tissue are sutured together. 2. occurs when a contaminated wound is left open and sutured closed after the infection is control. (basically the wound is left open until infection is controlled and then sutured back together) phases of repair: tertiary intention immature connective tissue cells that migrate into the healing site and secrete collagen. fibroblasts 1. surgical/nonsurgical 2. acute/chronic 3. superficial(epidermis) 4. partial thickness(extend into the dermis) 5. full thickness(affect underlying structures such as muscle, tendon, bone) 6. Color(red, yellow, black) with color, it will may have 2 or 3 colors at the same time. In this situationclassify according to the least desirable color present. wound classification: malnutrition, obesity, decrease blood supply, tissue trauma, smoking, drugs, wound debris such as necrotic tissue and infection. complications of healing 1. wound should be thoroughly assessed on admission in on a regular basis thereafter. 2. assess and document changes frequently. 3. Record the consistency, color, odor of any drainage and report is abnormal for situation. 4. report if not healing within normal period of time. nursing assessment tx: protection and gentle cleansing (if indicated) 1. keep slightly moist, protect from further trauma. dressing material: keep clean/slightly moist. use transparent film or adhesive semi permeable dressing (Op-site, /Tegaderm) healing: red wounds 1. use an absorbing dressing that absorbs exudate and cleanses the wound surface. 2. remove when saturated with exudate, they should be removed by washing with sterile saline or water. 3. the when must be gently cleansed to prevent damage to newly formed tissue. dressing material: hydrocolloid dressing (duoDerm). healing: yellow wounds