M4L3: Inflammation

Inflammatory process

Inflammatory process

The naturally occurring protective response of the body to a threat in terms of tissue damage

Inflammatory process

This process defends the body against harm, it aims to rid the body of damaged tissue and promotes the restoration of normal tissue.

Dolor

(Cardinal Signs of Inflammation)

Pain

Pain

(Cardinal Signs of Inflammation)

Occurs with the release of chemicals secondary to the damage of cells and tissue

Calor

(Cardinal Signs of Inflammation)

Heat and Warmth

Heat and Warmth

(Cardinal Signs of Inflammation)

Occur as the result of the vasodilation and the increased blood flow to the affected area

Rubor

(Cardinal Signs of Inflammation)

Redness

Redness

(Cardinal Signs of Inflammation)

Results from the vasodilation of blood vessels that occurs in response to the injury

Tumour

(Cardinal Signs of Inflammation)

Swelling

Swelling

(Cardinal Signs of Inflammation)

Occurs as the body's fluids enter the area of the injury and tissue damage

Dysfunction of the area

(Cardinal Signs of Inflammation)

Occurs as the result of the swelling and pain associated with the inflammatory process

Inflammatory Response

Major function of the natural immune system that is elicited in response to tissue injury or invading organisms.

Inflammatory Response

Facilitated by physical and chemical barriers that are part of the human organism.

Chemical mediators

(Inflammatory Response)

___ ___ assist this response by:
- Minimizing blood loss
- Walling off the invading organism
- Activating phagocytes
- Promoting the formation of fibrous scar tissue and regeneration of injured tissue

Inflammatory Response

It can be acute (lasting for a few days) or chronic (in response to an ongoing and unresolved insult)

Histamine

(Inflammatory Response)

Secreted by basophils and mast cells causes capillaries to become more permeable to white blood cells and other proteins, which proceed to target and attack foreign bodies in the affected tissue

Kinins

(Inflammatory Response)

Proteins in the blood that cause inflammation

Prostaglandins

(Inflammatory Response)

Hormones created during a chemical reaction at the site where an injury or other issue occurs.

Prostaglandins

(Inflammatory Response)

Play a key role in inflammation by contributing to the development of redness, swelling, heat, and pain

Vascular phase

Cellular phase

Phases of Acute Inflammation (2)

Vascular Phase

(Phases of Acute Inflammation)

Small blood vessels adjacent to the injury dilate (vasodilatation) and blood flow to the area increase

Endothelial cells

(Phases of Acute Inflammation: Vascular Phase)

___ ___ initially swell, then contract to increase the space between them, thereby increasing the permeability of the vascular barrier.

Exudation of fluid

(Phases of Acute Inflammation: Vascular Phase)

___ ___ ___ leads to a net loss of fluid from the vascular space into the interstitial space, resulting in edema (tumor)

Increased tissue fluid

(Phases of Acute Inflammation: Vascular Phase)

___ ___ ___ acts as a medium through which inflammatory proteins (such as complement and immunoglobulins) can migrate. It may also help to remove pathogens and cell debris in the area through lymphatic drainage

lymphatic drainage

(Phases of Acute Inflammation: Vascular Phase)

Increased tissue fluid acts as a medium through which inflammatory proteins (such as complement and immunoglobulins) can migrate. It may also help to remove pathogens and cell debris in the area through ___ ___

Cellular Phase

(Phases of Acute Inflammation)

Predominant cell of acute inflammation is the neutrophil which is attracted to the site of injury by the presence of chemotaxins, the mediators released into the blood immediately after the insult

neutrophil

(Phases of Acute Inflammation: Cellular Phase)
Predominant cell of acute inflammation is the ____ which is attracted to the site of injury by the presence of chemotaxins, the mediators released into the blood immediately after the insult

chemotaxins

(Phases of Acute Inflammation: Cellular Phase)

Predominant cell of acute inflammation is the neutrophil which is attracted to the site of injury by the presence of ___, the mediators released into the blood immediately after the insult

chemotaxins

(Phases of Acute Inflammation: Cellular Phase)

A substance released by bacteria, injured tissue, and white blood cells that stimulates the movement of neutrophils and other white blood cells to the injured area

- Margination
- Rolling
- Adhesion
- Emigration

(Phases of Acute Inflammation: Cellular Phase)

The migration of neutrophils occurs in four stages

Margination

(Phases of Acute Inflammation: Cellular Phase - Migration of neutrophils)

Cells line up against the endothelium

Rolling

(Phases of Acute Inflammation: Cellular Phase - Migration of neutrophils)

Close contact with and roll along the endothelium

Adhesion

(Phases of Acute Inflammation: Cellular Phase - Migration of neutrophils)

Connecting to the endothelial wall

Emigration

(Phases of Acute Inflammation: Cellular Phase - Migration of neutrophils)

Cells move through the vessel wall to the affected area

cascade of healing

(Healing Process)

When the skin is injured, our body sets into motion an automatic series of events, often referred to as the “___ ___ ___” in order to repair the injured tissues

Homeostasis/bleeding phase

Inflammation phase

Proliferative and granulation phase

Maturation/remodeling phase

(Healing Process)

Stages of wound healing (4)

The homeostasis/bleeding phase

(Healing Process: Stages of Wound Healing)

Is accompanied by vasoconstriction, thrombin formation, platelet formation, and the formation of a fibrin mesh for healing that begins the healing process

The homeostasis/bleeding phase

(Healing Process: Stages of Wound Healing)

The body activates its emergency repair system, the blood clotting system, and forms a dam to block the drainage

The inflammation phase

(Healing Process: Stages of Wound Healing)

Also referred to as the lag or exudate phase is accompanied by pain, swelling, edema, and the beginning of wound debris removal with phagocytosis to prevent infection

The proliferative and granulation phase

(Healing Process: Stages of Wound Healing)

Is accompanied with the fibroblastic production of granulation tissue and collagen

The maturation/remodeling phase

(Healing Process: Stages of Wound Healing)

Is characterized by the continued development and maturation of the fragile skin over the wound.

The maturation/remodeling phase

(Healing Process: Stages of Wound Healing)

This phase can last up to two years during which time the wound remains at risk and vulnerable for injury until full healing and good tensile strength is complete

Thermoregulation

(Healing Process: Nursing Management)

Monitor temperature as frequently as is appropriate to evaluate patient status.

Thermoregulation

(Healing Process: Nursing Management)

Monitor blood pressure, pulse, and respiration to determine responses to increased temperature.

antipyretic

(Healing Process: Nursing Management - Thermoregulation)

Administer ___ medication to lower temperature.

Thermoregulation

(Healing Process: Nursing Management)

Cover the patient with only a sheet to aid in lowering body temperature

hypothermia

(Healing Process: Nursing Management - Thermoregulation)

Monitor temperature closely to prevent treatment-induced ___, which will cause a rebound rise in temperature.

Fluid Balance

(Healing Process: Nursing Management)

Monitor fluid status including intake and output and insensible fluid loss (e.g., diaphoresis) to determine risk for or presence of fluid volume deficit.

fluid volume deficit

(Healing Process: Nursing Management - Fluid Balance)

Monitor fluid status including intake and output and insensible fluid loss (e.g., diaphoresis) to determine risk for or presence of ___ ___ ___.

oral fluid intake

(Healing Process: Nursing Management - Fluid Balance)

Encourage ___ ___ ___ to promote fluid balance.

fluid loss

(Healing Process: Nursing Management - Fluid Balance)

Monitor weight because ___ ___ is reflected in decreasing body weight.

IV infusion flow rate

(Healing Process: Nursing Management - Fluid Balance)

Maintain a steady ___ ___ ___ ___ to replace fluid lost as a result of fever and diaphoresis.

hypovolemia

(Healing Process: Nursing Management - Fluid Balance)

Monitor vital signs because increasing pulse and respirations and decreasing blood pressure can indicate ___

fluid deficit

(Healing Process: Nursing Management - Fluid Balance)

Observe for indications of dehydration (e.g., poor skin turgor, delayed capillary refill, weak or thready pulse, severe thirst, dry mucous membranes, decreased urine output, hypotension) to ensure early treatment of ___ ___

ambulation

(Healing Process: Nursing Management - Fluid Balance)

Assist the patient with ___ in case of postural hypotension, which results from hypovolemia

Tissue Integrity: Skin and Mucous Membrane

(Healing Process: Nursing Management)

Use an established risk assessment tool to monitor an individual’s risk factors (e.g., Braden scale) to reduce or eliminate factors that contribute to the development or progression of the pressure ulcer.

Tissue Integrity: Skin and Mucous Membrane

(Healing Process: Nursing Management)

Document any previous incidences of pressure ulcer formation to identify specific risks to the patient.

maceration

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Remove excessive moisture on the skin resulting from perspiration, wound drainage, and fecal or urinary incontinence to prevent ___.

massaging

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Avoid ___ over bony prominences to prevent further tissue damage

1 to 2

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Turn every ___ to ___ hours to avoid prolonged pressure in one area.

care

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Turn with ___ (e.g., avoid shearing) to prevent injury to fragile skin.

pillows

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Position with ___ to elevate pressure points off the bed.

pressure relief and increase circulation

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Use specialty beds and mattresses as needed to provide ___ ___ and ___ ___ to the site.

pressure

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Use devices on the bed (e.g., sheepskin) that protect the individual from ___

elbow and heel protectors

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Apply ___ and ___ ___ as appropriate to avoid pressure.

pressure ulcers

(Healing Process: Nursing Management - Tissue Integrity: Skin and Mucous Membrane)

Assist individual in maintaining a healthy weight as the risk for ___ ___ is increased in people who are obese or very thin.