NURS 2500 - Week 6: Inflammation + Tissue Integrity

What is inflammation? (1.1)

• an immunological defense against tissue injury, infection, or allergy

  • a protective process started to minimize/remove the pathological agent or stimulus triggering infection + to promote healing

What is acute inflammation? (2)

• local - at site injury; organ infection

• systemic - illness, or widespread infection

What is chronic infection? (2)

• local - persistent infection

• systemic - autoimmune disease

What are triggers for inflammation?

• mechanical trauma

• thermal, electrical, chemical injury

• radiation damage

• biological assault (infection)

What is the goal of the normal inflammatory response? (2)

• restore normal function of cells

• fibrous repair when cells can’t be restored

What is the physiological process for the normal inflammatory response?

• WBC + chemicals that serve to protect the body from invaders/cell/tissue damage are involved

What are the stages of the inflammatory response? (4)

• tissue injury + chemical mediator release

• vascular response

• cellular response

• tissue repair + replacement

What occurs in tissue injury? (1.4 + 1)

• damaged tissue releases chemical mediators:

  • histamine

  • prostaglandins

  • cytokines

  • kinins

• arachidonic acid is released

What is arachidonic acid? (2.1)

• precursor that leads to production of COX enzymes = prostaglandins

• can also lead to production of LOX enzyme = leukotrienes

  • released by damaged cells

What is chemotaxis? (1.1)

• a complex process involving more than a dozen different chemicals (proinflammatory enzymes)

  • results in WBC attraction to inflammation site when it (chemotaxis) occurs

What is chemotaxis stimulated by? (4)

• bacteria/viral exotoxins

• degenerative byproducts of inflammation

• products of complement system activation

• reactive products of plasma clotting

What are types of proinflammatory hormones? (3)

• prostaglandins

• histamines

• cytokines

What are the functions of proinflammatory hormones? (7)

• increase blood flow to area of injury

• increase vascular permeability

• activates components of an immune response

• attracts leukocytes to area of injury

• promotes angiogenesis

• stimulates connective tissue growth

• causes fever

What occurs in the vascular response (stage 1 of inflammation process)? (1.1.2 + 1.1)

• injured tissues + local granulocytes + tissue masts secrete proinflammatory hormones

  • small veins constrict, small arterioles dilate

    • increases blood flow delivering nutrients to injured tissue (= hyperemia, warmth, edema)

    • capillary leak/permeability (= swelling/edema, pain)

• macrophages secrete proinflammatory hormones

  • WBC mature quicker + promote neutrophil invasion

What are the types of WBCs? (1.3 + 1.2.3)

• granulocytes

  • neutrophils

  • eosinophils

  • basophils

• agranulocytes

  • lymphocytes

    • B lymphocyte

    • T lymphocyte

    • natural killer cells

  • monocytes

What is the order that WBCs arrive at the site of injury? (3)

• 1 - neutrophils

• 2 - monocytes

• eosinophils, basophils, and lymphocytes arrive later

What occurs in the cellular response (stage 2 of inflammation)? (1.2 + 3)

• granulocytes and tissue mast cells activate

  • neutrophilia occurs 12 hrs after injury = phagocytosis begins

  • eosinophils, basophils, and tissue mast cells promote continuous inflammatory response

• exudate forms - dead WBCs, necrotic tissue, leaked cell fluid

• macrophages increase + stimulate monocyte production

• arachidonic acid cascade

What is the arachidonic acid cascade? (2)

• fatty acids in membranes of injured cells → arachidonic acid

• then converted (by COX) → substances (histamine, leukotrienes, prostaglandins, serotonin, kininis) that promote more inflammation

What is the margination + diapedesis of blood leukocytes? (2)

• margination - WBCs move from center of bloodstream → endothelium of blood vessels

• diapedesis - WBCS change shape with projections to leave walls → tissues

What occurs in tissue repair + replacement (stage 3 of inflammation)? (1.1 + 2.1)

• all WBCS involved start the replacement of tissues by stimulating healthy cells to divide

  • WBCS trigger angiogenesis (blood vessel growth) + scar tissue formation for cells that can’t divide

• regeneration occurs - replacement of lost cells/tissues with cells of same type

• repair - result of lost cells being replaced with connective tissue

  • occurs simultaneously with stage 1 + 2

What is the duration of acute inflammation? (2)

• stage 1-2 - 3-5 days

• stage 3 - 2-3 weeks

What are characteristics of acute inflammation? (3)

• leaves no lasting damage (inflammation, not injury)

• neutrophils are predominant cell type at site of inflammation

• C reactive protein is the inflammatory marker

What are characteristics of chronic inflammation? (1.3 + 2)

• lymphocytes + macrophages are the star

  • release tissue thromboplastin

  • removes necrotic tissue + pathogens

  • continues release of pro-inflammatory cells

• thickening + scarring of connective tissue

• may be subclinical

What is the function of thromboplastin? (2)

• facilitates hemostasis

• promotes fibroblasts

How do you assess a local response vs a systemic response? (4)

• extensiveness

• location

• dependent on pt immune response

• dependent on acute vs chronic process

What are the components of a local response? (6)

• swelling

• pain

• warmth

• redness

• exudate

• impaired function

What are the components of a systemic response? (5)

• leukocytosis

• fever

• malaise

• nausea, anorexia

• muscle catabolism

What are diagnostics for inflammation? (1.3 + 1.3)

• imaging

  • CT

  • MRI

  • endoscopy

• blood test

  • CRP

  • ESR

  • WBC

What is a normal total WBC count?

• 5-10 × 10(9) x /L

What is a normal segmented WBC count?

• 3.0-5.8 ×10(9) x/L

What is a normal bands WBC count?

• 0.25-0.5 ×10(9) x/L

What is a normal monocyte count?

• 0.3-0.5 × 10(9) x/L

What is a normal lymphocyte count?

• 1.5-3.0 × 10(9) x/L

What is a normal eosinophil count?

• 0.0-0.25 × 10(9) x/L

What is a normal basophil count?

• 0.01-0.04 x 10(9) x/L

What is a normal ESR value?

• <20 mm/hr

What is a normal CPR value? (1.2)

• <1mg/L

  • 1-10 = inflammation

  • 10+ = severe infection

What does an elevated total WBC mean? (2)

• acute infection

• inflammatory response actively occuring

What does an elevated bands WBC count mean?

• severe acute infection

What does an elevated lymphocyte count mean?

• viral infection

What does an elevated eosinophil and basophil count mean?

• allergic hypersensitivity reaction

• parasitic infection

What is the ESR count used for?

• looking at chronic illness progression

How do you manage inflammation? (2)

• infection - eliminate cause

• hypersensitivity - response manage inflammation + manage pathologic issue

How do you manage inflammation of a sprain/strain? (2)

• RICE

• NSAIDS

How do you manage chronic inflammation? (4)

• monitor to prevent further tissue damage

• treat cause

• support tissue function

• medications

How do you use RICE for the first 24-48 hours after injury (4)

• rest to minimize further reinjury + trigger inflammation

• ice for 10 mins every 2-3 hrs

• compression to reduce swelling

• elevate above level of hear to minimize swelling

Where do NSAIDS work vs steroids? (2)

• NSAIDS - block arachidonic pathway

• steroids - block phospholipase → arachidonic acid

How do glucocorticoids work? (1.2)

• suppress histamine release

  • inhibits synthesis of prostaglandins by COX II pathway

  • suppresses some phagocytes + lymphocytes

What is the MOA for prednisone? (1.2)

• decreases inflammation through suppressing immune responses

  • inhibits macrophage accumulation

  • reduced capillary permeability

What are the therapeutic effects of prednisone? (2)

• active inflammation - reduced inflammation

• chronic inflammation - reduced active disease

What is the administration for prednisone? (2.1)

• short term - higher dose

• long term - smaller doses

  • cannot stop abruptly; must be tapered slowly (+10 days use)

What are the indications for prednisone? (4)

• used for a wide variety of chronic illnesses but reversed for acute/severe exacerbations unresponsive to conventional therapy

• severe allergic reactions

• endocrine disorders

• respiratory disorders

What are the contraindications for prednisone? (4)

• hypersensitivity

• active untreated infections

• avoid chronic use

• drug to drug - use with caution with NSAIDS

What are side effects of prednisone? (9)

• fluid retention

• HTN

• bruising/thinning of skin, acne, decreased wound healing

• adrenal insufficiency

• peptic ulcer

• osteoporosis - long term use

• mood disturbances

• hyperglycemia

• cushings

What are nursing considerations for prednisone? (5)

• assess area of concern depending on indication use

• assess for adrenal insufficiency

• monitor daily weights/bp/sign of fluid retention

• monitor labs - sodium, potassium, glucose

• monitor signs of infection

What is sudden withdrawal + adrenal crisis? (3)

• adrenal glands controlled by release of ACTH from pituitary gland by negative feedback

• exogenous cortisol suppresses pituitary release of ACTH + natural cortisol production

• adrenal crisis is the result of sudden withdrawal

What are the symptoms of adrenal crisis? (4)

• hypotension

• flu symptoms

• seizures

• shock

What is tissue integrity?

• state of structurally intact + physiologically functioning epithelial tissues

What is the function of the epidermis + dermis? (7)

• protection

• perception

• temperature regulation

• communication

• wound repair

• absorption + excretion

• production of vitamin D

What is sublethal cell injury?

• changes that can be potentially reversible if the harmful stimulus is removed

What is lethal injury?

• irreversible processes that cause cell death

What are the types of cell death? (2)

• apoptosis

• necrosis

What is apoptosis?

• programmed cell death

What is necrosis?

• tissue death from various causes

What are types of necrosis? (4.2)

• coagulative

• liquefactive

• caseous

• gangrene

  • dry

  • wet

What is dry gangrene?

• degenerative changes occurring with certain chronic diseases where blood supply is gradually reduced

What is wet gangrene? (1.1)

• sudden rapid elimination of blood flow

  • extensive tissue liquefaction makes affected area soft + malodorous

What are types of adaptive + maladaptive processes? (6)

• hypertrophy

• hyperplasia

• atrophy

• metaplasia

• dysplasia

• anaplasia

What is hypertrophy?

• expansion of size in cells = increased issue mass without cell division

What is hyperplasia?

• multiplication of cells as a result of increased cell division

What is atrophy?

• decrease in size of tissue/organ as a result of reduction of number/size of cells

What is metaplasia?

• transformation of one cell type → another due to change in physiological condition or external irritant

What is dysplasia?

• abnormal differentiation of diving cells = changes in size, shape, and appearance

What is anaplasia?

• cell differentiation to a more immature form

What are the categories of impaired tissue integrity? (6)

• trauma/injury

• loss of perfusion

• immunologic reaction

• infection/infestation

• thermal/radiation injury

• lesions

What is trauma/injury?

• intentional/unintentional wound penetrating the skin + SQ layers or superficial abrasion/scrape

What does a loss of perfusion lead to?

• prolonged = tissue necrosis

What are immunologic reactions?

• redness/rash/hives → steven johnson syndrome

What are infections/infestations?

• bacteria, virus, fungi

What is a thermal/radiation injury?

• sunburns → burns, radiation therapy, frostbite

What are lesions?

• benign → invasive

What is first intention healing? (2.1)

• minimal injury

• not as deep

  • ex - lacerations, surgical incisions, puncture

What are the stages of healing in first intention healing? (1.2 + 1.3 + 1.1)

• blood clot forms

  • platelets + fibrin solidify clot to seal wound + stop further bleeding + pathogen entry

  • cytokines release to encourage other cellular nutrients to come out of blood supply to repair site

• acute inflammation + granulation tissue

  • vasodliation

  • exudate from released fluid

  • granulation tissue forms deep in tissue, angiogenesis occurs

• scar tissue + remodeling

  • fibroblasts lay down collagen to strengthen tissue

What is second intention healing?

• more severe/deep tissue injury

What are the stages of second intention healing? (1.2 + 1.3 + 1.2)

• blood clot forms

  • platelets + fibrin solidify clot to seal wound + stop further bleeding + pathogen entry

  • cytokines release to encourage other cellular nutrients to come out of blood supply to repair site

• chronic inflammation + granulation tissue

  • more exudate, more swelling, greater risk of infection

  • neutrophils have more to clean + protect against

  • granulation phase takes longer; more scarring, more vulnerable to injury

• scar tissue + remodeling

  • fibroblasts lay down collagen

  • takes longer + uses stronger collagen to pull wound closed

What is granulation tissue?

• new connective tissue + microscopic blood vessels that form on the surface of a wound

What is Addison’s disease?

• increased melanin production stimulated by cortisol deficiency

What is jaundice?

• increased serum bilirubin due to liver inflammation or hemolytic disease

What is erythema + the types? (1.4)

• redness of the skin

  • polycythemia - too many blood cells

  • hyperemia - excess blood flow

  • carbon monoxide poisoning

  • venous stasis - blood pooling

How are wounds classified? (2)

• cause

• lesions

How are wounds classified by cause? (5)

• surgical vs nonsurgical

• underlying pathology

• duration

• level of contamination

• type of tissue affected

How are lesions classified? (1.3 + 1.2)

• common shapes/configurations

  • zosteriform - herpes zoster

  • grouped - dermatitis

  • confluent - hives

• primary + secondary

  • lesion developed on unaltered skin - primary

  • lesion changing over time from infection/scratching - secondary

What are types of primary lesions? (5)

• macule - freckle

• papule - mole

• wheal - allergic reaction

• vesicle - blister, cavity w/ fluid

• pustule - cavity with pus

What are types of secondary lesions? (1.2 + 1.4 + 1)

• debris on skin

  • crust

  • scale

• break in continuity of surface

  • fissure

  • erosion

  • ulcer

  • excoriation

• scars

What are the types of wound bed colours? (3)

• red

• yellow

• black

What is granulation tissue as a wound bed colour?

• red

  • superficial or deep that is clean, red/pink

What is slough?

• wet/necrotic tissue creating an environment for bacterial growth

What is eschar?

• thick, dry, necrotic tissue that is black, grey, brown

What are pressure injuries?

• localized injuries to the skin/underlying soft tissue (usually over a body prominence)

What are the causes of pressure injuries? (4)

• pressure

• shearing force

• friction

• excessive moisture