is a defensive response of vascularized living tissue to cellular injury caused by endogenous or exogenous agents defined as the entire complex

x of tissue changes in reaction to injury The causation,location & extent of the tissue injury may vary but the sequence of physiologic events that constitutes the inflammatory response is very similar the goal of inflammatory response is essentially to rid the organism of both the initial cause of injury & the consequences of the injury the sequence of events in the inflammatory response culminates in the healing process CAUSES OF INFLAMMATION: 1. Infection from microorganisms in the tissues 2. Physical trauma, often with the release of free blood in the tissues 3. Chemical,irradiation,mechanical or thermal injury causing direct irritation to the tissues 4. Immune reactions causing tissue-damaging hypersensitive responses

INJURY Transient vasoconstriction Changes in microcirculation Release of chemical Substances (Histamine,Kinins,Prostaglandin) vasodilation Increase rate Of blood flow LOCAL HEAT/ REDNESS Increase vascular permeability Plasma fluid leaked into the inflamed tissues

Leukocytic cellular infiltration

As blood flow Fluid leaks into the Surrounding tissues Formed elements (RBC,WBC & Platelets) remain in the blood

Plasma fluid leaked into the inflamed tissues SWELLING Irritation of nerve endings by chemical mediators Pressure of fluids or swelling on nerve endings Release of Bradykinin Fibrinogen coagulates Forms Fibrin Clot formation PAIN LOSS OF FUNCTION

Hemoconcentration
Leukocytes exit & migrate to the site of injury Engulf offending organisms & remove cellular debris (phagocytosis)

Release of endogenous pyrogens from neutrophils & macrophages

Reset the hypothalamic thermostat FEVER Leukocytosis Wall the injured Area & prevent the Spread of infection MALAISE ANOREXIA BODY ACHES WEAKNESS

Cellular injury

Migration of leukocytes to inflamed area to engulf foreign material

Plasma fluids, leukocytes,chemical mediators leak into inflamed area

Vasodilation & increase vascular permeability

TYPES OF INFLAMMATION

is the immediate & early response to an injurious agent lasting from minutes to several days & is characterized by vascular & cellular alterations

1. ACUTE INFLAMMATION:

2. CHRONIC INFLAMMATION:
longer duration & follows a persistent, self perpetuating course with the source of inflammation being unresolved may either result in healing or develop into granulomatous inflammation that does not serve a beneficial & protective function
Nature of exudate becomes proliferative Cycle of cellular infiltration,necrosis, fibrosis with repair & breakdown occuring simultaneously Scarring may occur Tissue damage

Although the inflammatory response is usually beneficial, it can be excessive resulting in additional cellular injury or SIRS which often leads to multiple organ failure

 The integumentary system comprises the skin, hair, nails, and glands of the skin largest organ in the body that: provides protection and sensation regulates fluid balance & temperature produces vitamins (vitamin D) and immune system components it has 3 layers: 1. Epidermis:

outermost layer of the skin made up of dead epithelial cells replaced every 3 to 4 weeks contain keratin, an insoluble fibrous protein; the principal component that hardens the hair and nails; prevents excessive fluid loss from the body & repels pathogens. contain melanin for pigmentation epidermis and dermis interlock and produce ripples on the surface of the skin

2. Dermis:
largest portion of the skin & provides strength and structure upper papillary layer contains fibroblast cells, which produce collagen; This is the basis of the connective tissue. produces elastic bundles, which give skin flexibility blood vessels, lymph ducts, nerves, sebaceous and sweat glands, & hair roots are also contained hair follicles are lined with epithelial cells

3. Subcutaneous:
innermost layer of skin primary tissue is adipose, which provides cushioning between the skin layers, the muscle, and the bone provides shape, and its insulating properties are essential in regulation of body temperature

Skin Subcutaneous (yellow) Anterior fascia (white) Muscle (red) Peritoneum (thin white) Viscera

1. Inflammatory/Exudative Phase
occurs from the time of violation of skin integrity until approximately the fourth day there is increased blood supply to the area, which brings fibrin as the body attempts to clot off any bleeding vessels the blood clot or scab, this natural covering mechanism creates a new barrier for the broken skin to protect the underlying tissues from harmful bacterial invasion inflammatory response occurs

2. Proliferative /Fibroblastive/ Connective Tissue Phase

This lasts from day 5 through day 20 Fibroblasts work to synthesize collagen and connective tissues capillary growth is occurring via the fibrin network, which started in the inflammatory phase development of the characteristic red velvety granulation tissue. epithelial cells begin to migrate from the edges of the wound across the healthy moist granulation bed

develop eschar if there is a lack of healthy blood flow to the capillaries or a lack of moisture;composed of dried plasma proteins and dead skin cells

3. Maturation/Differentiation/ Resorptive/ Remodeling/Plateau Phase

final phase lasts from day 21 and even up to months or years after the wound has occurred The collagen fibers finally reorganize to give the wound strength, and the epithelial surface cells mature Scar tissue forms, and the wound begins to remodel scarred wound is strong, but the tissue is less elastic than the original uninjured skin

 Young people have more elasticity to skin, connective tissue is stronger, & more resilient to factors that can cause wounds; The elderly lose elasticity of collagen,less fat deposition, and, therefore,less protective mechanism. Skin becomes more friable and easily damaged. elderly may also have chronic diseases that cause loss of circulation either at the macro or micro levels; Atherosclerosis or peripheral vascular disease can effect arterial circulation, which leads to poor perfusion to the extremities

1. Age :

2. Nutrition:
Lack of nutrients to skin, either from lack of intake or lack of adequate tissue perfusion/nourishment of tissues affect the health of skin and wound healing

5. Risk Predictors: 3. Lifestyle:

The Braden Scale for Predicting Pressure Exercise increases circulation and Sore Risk is a validated predictive tool used to assess patients' risks for impaired skin tissue perfusion integrity Smoking decreases functional Six factors are assessed to determine hemoglobin, which is much needed Risk for skin breakdown it include: by impaired skin tissues for healing; 1. the ability to respond to discomfort/ increases platelet aggregation that sensory perception impair circulation to tissues 2. the degree to which skin is exposed to Caffeine & stress responses cause Moisture vasoconstriction; leads to decreased 3. the degree of physical activity tissue perfusion and delays healing. 4. the ability to change and control body 4. Medications : position Antiinflammatory agents delay healing 5. the usual food intake pattern by suppressing the normal immune system 6. The problem, or potential problem, of Steroids block natural inflammatory friction and shear processes, which bring needed white cells to areas of damage Prolonged use of antibiotics puts the patient at risk for superinfection

 closure of a surgical site or other wound is performed after necessary hemostasis Has been achieved wounds include deep & superficial structures methods of wound closure include sutures,staples, clips, tapes & glues

SUTURES
as a noun is used for any strand of material used for ligating or approximating tissue; it is also synonymous with stitch as a verb denotes the act of sewing by bringing tissues together & holding them until healing has taken place LIGATURE /TIE: if the material is tied around a blood vessel to occlude the lumen STICK TIE / SUTURE LIGATURE: a suture attached to a needle for a single stitch for hemostasis FREE TIE: is a single strand of material handed to the surgeon or assistant to ligate a vessel TIE ON A PASSER: a tie handed to the surgeon in the tip of a forceps

METHODS OF SUTURING the edges of the wound are intentionally directed by the placement of sutures during closure 1. EVERTING SUTURES: these interrupted (individual stitches) continuous (running stitch) sutures are used for skin edges A. SIMPLE CONTINUOUS (RUNNING): this suture can be used to close multiple layers with one suture;the suture is not cut until the full length is incorporated into the tissue(Fig. 28-2, A) B. SIMPLE INTERRUPTED: each individual stitch is placed tied & cut in succession from one suture (Fig. 28-2, C) C. CONTINUOUS RUNNING / LOCKING (BLANKET STITCH): a single suture is passed in & out of the tissue layers & looped through the free end before the needle is passed through the tissue for another stitch;each new stitch locks the previous stitch in place (Fig 28-2 B) D. HORIZONTAL MATTRESS: stitches are placed parallel to wound edges;each single bite takes the place of two interrupted stitches (Fig. 28-2, D) E. VERTICAL MATTRESS: this sutures uses deep & superficial bites, with each stitch crossing the wound at right angles;it works well for deep wounds;edges approximate well (Fig. 28-2, E)

METHODS OF SUTURING 2. INVERTING SUTURES: these sutures are commonly used for two layer anastomosis of hollow internal organs, such as the bowel & stomach A. B. C. D. E. HALSTED SUTURE CONNELL SUTURE CUSHING SUTURE GREY-TURNER SUTURE PURSE-STRING SUTURE SUTURE MATERIAL

1. ABSORBABLE SUTURES: sterile strands prepared from collagen derived from healthy mammals or from synthetic polymer; they are capable of being absorbed by living mammalian tissue but may be treated to modify resistance to absorption Ex. Gut, Vicryl, Chromic 2. NONABSORBABLE SUTURES: strands of natural or synthetic material that effectively resist enzymatic digestion or absorption in living tissue Ex. Silk, cotton

SURGICAL NEEDLES are needed to safely carry suture material through tissue with the least amount of Trauma the best surgical needles are made of high quality tempered steel that is: Strong enough so that it does not break easily Rigid enough to prevent excessive bending yet flexible enough to prevent breaking after bending Sharp enough to penetrate tissue with minimal resistance Approximately the same diameter as the suture material it carries to minimize trauma in passage through tissue Appropriate in shape & size for the type, condition & accessibility of the tissue to be sutured Free from corrosion & burns to prevent infection & tissue trauma

BASIC SHAPES OF NEEDLES 1. CUTTING POINT: a razor-sharp, honed cutting point may be preferred when tissue is difficult to penetrate such as skin, tendon & tough tissues in the eye these make a slight cut in tissue as they penetrate 2. TAPER POINT: these needles are used in soft tissues, such as intestine & peritoneum which offer a small amount of resistance to the needle as it passes through they tend to push the tissue aside as they go through, rather than cut it the body tapers to a sharp point at the tip 3. BLUNT POINT:

are designed with a rounded blunt point at the tip they are use primarily for suturing friable tissue such as liver & kidney wherein it is less apt to puncture a vessel in these organs than is a sharp pointed needle it may also be used in some tissues to reduce the potential for needle sticks, especially in general & gynecologic surgery

TRANSVERSE INCISION

UPPER MIDLINE INCISION

MCBURNEY INCISION

LOWER MIDLINE INCISION PHANNENSTEIL

1. Intentional wounds
are those that are purposefully created for therapeutic reasons These are wounds that are created under sterile conditions and are closed immediately after the intervention to repair the skin integrity and prevent infection. e.g. surgical incisions or venipuncture

3. Closed wound
is one where the skin remains intact e.g. ecchymosis (bruising) or hematomas (collections of blood under the skin).

4. Open wounds

are those where the skin or mucous membranes are broken: incisions, punctures, and abrasions.

2. Unintentional wounds
are those that are accidental; more prone to infection because of the dirty nature of the accident e.g. traumatic wounds: compound fracture, a gunshot wound, or an abrasion from an accident

Wounds are also defined in terms of the 5. Abrasions cause of the wound caused from friction on the skin; Skin is torn, and a large area of skin can be involved 1. Incised wound e.g. A fall or sliding on rough gravel would is when is a cut in the skin;the edges cause this type of wound;when a patient is are clean;it can be from an unintentional pulled up in bed without the use of a lift cause, or intentional sheet. 2. Laceration 6. Puncture the tissue edges of the cut are torn is a stab by a blunt or sharp instrument and irregular & from an unintentional that pierces and enters the skin. cause e.g. intramuscular injection, or placement 3. Contusions of a postoperative drain using a trocar wound is caused from a blow from a blunt source. There is ecchymosis, (bruising) and 7. Penetrating a hematoma may be present 4. Avulsion wound is one in which an object passes through the skin or mucous membrane and lodges in underlying tissues. e.g. A bullet from a gunshot

injury is more severe. Entire sections of skin are peeled away by the traumatic forces

8. Pressure

9. Excessive moisture

on skin overlying boney prominences can can cause skin maceration from overhydration. This combined with cause compression of tissues leading to chemical irritation from urine or feces lack of perfusion of the skin tissues. can also cause significant skin Pressure over 32 mmHg for more than 2 hours, such as when a patient is not turned, damage. can lead to tissue ischemia and skin breakdown
9. Shear is a combination of pressure and friction, such as when a patient slides down in bed onto the coccyx when the head of the bed is elevated;These combined forces can also lead to breakdown

 Wounds are also classified in terms of their level of contamination

1. Clean wound:
is that which is closed or where there is no evidence of inflammation or infection. There is no entrance to the pulmonary, gastrointestinal (GI), or genitourinary (GU) tracts. A clean/uncontaminated wound is that where the skin is purposefully broken, such as with a surgical wound. The pulmonary or GU tracts may be entered, but there is no evidence of infection

2. Contaminated wound
is one where inflammation is evident and may involve entrance to the GI tract where spillage of fecal contents may occur. It may be unintentional or result from a break in sterile technique. dirty/infected wound is old draining purulent material, often deep, and is unintentional. e.g. Gunshot woundclassified as unintentional, open, and contaminated; compound fracture.

 Another classification involves wound thickness: 1. Partial-thickness wound involves only the epidermis and dermis of the skin;this wound may heal but needs supportive therapy to promote natural regeneration 2. Full-thickness wound involves the subcutaneous tissues and may include injury to muscle and bone; this type of wound requires tissue repair. RYB Color Code Wound Classifications: The red (R), yellow (Y), black (B) system for describing wounds involves determining interventions based on the basis of the color of the tissues 1. A red (protect) wound is a clean healthy wound showing evidence of granulation tissue;this wound only requires gentle cleansing & protection with a topical antimicrobial agent and/or a moisture retentive dressing.

2. A yellow (cleanse) wound

shows evidence of drainage & the presence of yellow eschar or slough; this thick/milky yellow tissue comprises dried plasma proteins and dead skin; this wound requires cleansing and debriding to remove nonviable tissues and may need an absorption dressing to minimize drainage. An antimicrobial agent is required. 3. A black (debride) wound contains necrotic tissue and eschar; this wound requires surgical, mechanical, autolytic, or chemical debridement.

is also called wound exudate, is an indicator of the health of an open wound 1. Serous drainage Culture & Sensitivity Test to determine appropriate is clear or slightly yellow. antimicrobial and/or antibiotic therapy. It is composed of plasma and water, the wound should be cleansed with this is what is found under a healthy normal saline first to remove skin blister. It is found in wounds as a product of the contaminants. Do not clean the wound with any antimicrobial solution, such normal inflammatory response & the as Betadine or hydrogen peroxide, accumulation of white blood cells before obtaining a culture, because 2. Purulent drainage this will cause inaccurate results of the test. Once cleansed, use a may have an odor and is thick, culturette swab to obtain drainage/ yellowish, or can be green, blue, or cells from all wound crevices & gray;these colors indicate the tunnels. Saturate the swab with the presence of microorganisms, such as pseudomonas;Wounds with preservative per manufacturer's recommendations. Then rapidly this type of drainage should be swabbed for a culture and sensitivity transport the swab to the laboratory for the most accurate analysis. (C&S)

3. Sanguinous wound drainage is that which is bloody. Bright red sanguineous drainage indicates new/fresh bleeding. This may be concerning in terms of the integrity of underlying vessels. Hemorrhage from wounds is a serious complication 4.Serosanguineous drainage is thin/watery and is pink or red. This indicates plasma and the presence of a few red blood cells. this drainage is seen from an incision in the initial postoperative period If significant drainage is expected, a wound drain may be used;the purpose is to promote healing by preventing drainage accumulation that could lead to infection or abscess formation. Drains reduce ecchymosis and control external wound drainage

Drain it is inserted through an intentional wound incision using a trocar to guide the drainage tube out of the body via either the incision or a stab wound lateral to the incision wound. may or may not be sutured to the skin. The passive or perforated drainage tube remains in the wound layers to collect oozing blood. A.Penrose drain, open (passive) drain provides a sinus tract for drainage to escape into a dressing or container B. Jackson Pratt (JP) drain a closed wound drain attached to a collection Reservoir; when the bulb is compressed, provides mild negative pressure suction & the ability to measure drainage as it is collected

C. Hemovac drain also decreases dead space as the spring mechanism of the drain is compressed. It provides negative pressure suction, collects drainage, & provides a measurement device. It can also be attached to wall suction.

4. Extreme care must be used with emptying drains to prevent contamination; The port for emptying the drain should not touch the surface of the measuring cup, & if this occurs, the port should be cleansed with alcohol

Nursing Considerations: 5. Accurate documentation & 1.All drains should be monitored frequently communication of the timing, amount, for drainage amount, quality & maintenance & quality of the drainage is important of suction as ordered 2. If a drain is not maintaining suction/ compression, the physician should be notified because there may be an air leak in the system 3. If drainage suddenly ceases, this may indicate clot formation in the drain tubing; this may cause the build-up of wound drainage & can lead to hematoma or abscess formation

 healing is when tissue edges are approximated and there is no loss of skin layers. The wound is glued, sutured, or stapled closed. There is minimal granulation or scarring. Epithelial bridging occurs rapidly & the wound has the appearance of being closed within the first week However, it is important to note that it takes time for the collagen fibers/ connective tissues to realign and heal with strength. This process of healing occurs from deep in the wound & progresses to the surface. Therefore, it is important that the wound remain supported/splinted to protect tissues to allow for uninterrupted healing.

 when the wound is left open;the edges of the wound are not approximated There is often loss of tissue, such as with a pressure/decubitus ulcer. Drainage is present, and the wound is prone to eschar or necrotic tissue. The wound is at increased risk for infection because the normal skin protective barrier is not present;the normal healing process occurs by the formation of granulation tissue. This takes longer, and there is more potential for scarring. this healing process takes longer than primary intention healing but is often the best option for large open wounds/wounds where infection has been present. A wound will not begin to develop healthy granulation tissue until eschar/necrotic/ infectious tissue has been removed/debrided;Premature closure of an infected wound can lead to abscess formation

 wound healing occurs when a wound has been closed initially (primary intention) but needs to be opened because of infection/abscess development. The wound is then supported to heal by the open process as described under second intention healing.