UNITY MEDICAL ACADEMY | UPNURSING NOTES

Inflammation and Wound Healing

Complete Nursing Notes | Clinical Concepts | NORCET Preparation

BSc Nursing • GNM • ANM • Medical-Surgical Nursing

📘 Learning Objectives

Understand inflammation and its types.
Explain the stages of acute inflammation.
Describe wound classification and wound healing phases.
Identify factors affecting wound healing.
Understand wound assessment, nursing management and complications.
Practice MCQs after completing the study notes.

1. Definition of Inflammation

Inflammation is a protective response of vascularized tissues to infection, injury or harmful stimuli. It involves immune cells, blood vessels and chemical mediators to eliminate the cause of injury, remove damaged tissue and initiate repair.

Inflammation is a defense mechanism, but excessive or persistent inflammation can also damage normal tissues.

Remember: Inflammation is not the same as infection. Inflammation may occur due to infection, trauma, burns, chemicals, autoimmune disease or other tissue injury.

2. Types of Inflammation

Feature	Acute Inflammation	Chronic Inflammation
Onset	Rapid	Usually gradual or persistent
Duration	Short-term	Prolonged
Predominant cells	Neutrophils	Macrophages, lymphocytes and plasma cells
Main features	Vascular changes, edema and leukocyte migration	Persistent inflammation, tissue destruction and repair
Examples	Acute appendicitis, acute wound inflammation	Tuberculosis, rheumatoid arthritis

Acute Inflammation

Acute inflammation is an immediate response to injury. It is characterized by vasodilation, increased vascular permeability and migration of leukocytes, especially neutrophils, to the affected area.

Chronic Inflammation

Chronic inflammation is a prolonged response in which inflammation, tissue destruction and healing may occur simultaneously. Macrophages and lymphocytes are important cells involved.

3. Cardinal Signs of Inflammation

Sign	Meaning	Cause
Rubor	Redness	Increased blood flow due to vasodilation
Calor	Heat	Increased local blood flow
Tumor	Swelling	Fluid accumulation in tissues
Dolor	Pain	Chemical mediators and tissue pressure
Functio laesa	Loss of function	Pain, swelling and tissue injury

Memory Trick: Redness + Heat + Swelling + Pain + Loss of Function.

4. Mechanism of Acute Inflammation

Step 1: Recognition of Injury

Tissue-resident immune cells recognize pathogens or damaged cells and release inflammatory mediators.

Step 2: Vasodilation

Local blood vessels dilate, increasing blood flow to the affected area. This contributes to redness and warmth.

Step 3: Increased Vascular Permeability

Fluid and plasma proteins move from blood vessels into the interstitial tissue, producing inflammatory edema.

Step 4: Leukocyte Recruitment

Leukocytes move from the bloodstream toward the site of injury. Neutrophils are usually prominent early in acute inflammation.

Step 5: Phagocytosis

Neutrophils and macrophages engulf and remove microorganisms, foreign material and cellular debris.

Step 6: Resolution or Repair

If the cause is controlled, inflammation may resolve. Depending on the extent of tissue damage, healing may occur by regeneration, scar formation or a combination of both.

Sequence for Exams:
Injury → Mediator Release → Vasodilation → Increased Permeability → Leukocyte Migration → Phagocytosis → Resolution/Repair

5. Chemical Mediators of Inflammation

Mediator	Important Action
Histamine	Vasodilation and increased vascular permeability.
Prostaglandins	Contribute to pain, fever and vasodilation.
Leukotrienes	Promote leukocyte recruitment; some cause bronchoconstriction and increased permeability.
Bradykinin	Promotes pain and increased vascular permeability.
Interleukin-1 (IL-1)	Promotes inflammatory responses and fever.
TNF (Tumor Necrosis Factor)	Promotes inflammation and endothelial activation.
Complement proteins	Help recruit and activate immune cells; some contribute to microbial lysis.

Exam Focus: Histamine is a key mediator of early vasodilation and increased vascular permeability.

6. Systemic Effects of Inflammation

Fever
Malaise and fatigue
Leukocytosis
Increased acute-phase proteins, such as C-reactive protein (CRP)
Increased erythrocyte sedimentation rate (ESR) in many inflammatory conditions
Tachycardia may occur with fever, pain or systemic illness

Clinical Note: These findings are nonspecific. They must be interpreted along with the patient's symptoms, examination and other investigations.

7. Wound: Definition and Classification

A wound is a disruption in the normal continuity of the skin, mucous membrane or underlying tissue.

A. Classification According to Cause

Wound Type	Description
Incision	A clean cut produced by a sharp object.
Laceration	A tear or irregular wound.
Abrasion	Superficial damage caused by friction.
Puncture	A narrow, deep wound caused by a pointed object.
Contusion	Blunt injury with tissue damage and bruising, often without an open wound.
Avulsion	Tissue is forcibly torn away from its normal position.

B. Classification According to Duration

Acute Wound

Usually follows an injury or surgery and progresses through an expected healing process.

Chronic Wound

Fails to progress through normal healing in an expected time. Examples include many diabetic foot and venous leg ulcers.

C. Classification According to Wound Contamination

Category	Description
Clean	No infection or inflammation; respiratory, alimentary, genital or urinary tract is not entered.
Clean-contaminated	Controlled entry into a normally colonized tract without unusual contamination.
Contaminated	Major break in sterile technique, significant spillage or certain fresh traumatic wounds.
Dirty/Infected	Existing infection, devitalized tissue or old traumatic wound with retained contamination.

Surgical wound classification is determined by the operative findings and applicable institutional definitions.

8. Wound Healing

Wound healing is the process through which the body repairs damaged tissue and restores the integrity of the skin or other affected structures.

Healing involves overlapping biological phases. The duration and appearance of each phase vary according to wound type, size, location, blood supply, infection and the patient's health.

Phases of Wound Healing

Phase	Approximate Timing	Major Events
Hemostasis	Immediately after injury	Vasoconstriction, platelet plug formation and fibrin clot formation.
Inflammatory	First several days	Neutrophils and macrophages remove microbes and debris; inflammatory mediators are released.
Proliferative	Begins within days; may continue for weeks	Granulation tissue formation, angiogenesis, fibroblast activity, collagen deposition and epithelialization.
Remodeling/Maturation	Weeks to months or longer	Collagen remodeling, wound contraction and increasing tensile strength.

1. Hemostasis Phase

Begins immediately after tissue injury.
Vasoconstriction helps reduce blood loss.
Platelets adhere and aggregate at the injury site.
Coagulation produces a fibrin clot.
The clot provides a temporary framework for repair.

2. Inflammatory Phase

Neutrophils arrive early and help remove microorganisms and debris.
Macrophages continue phagocytosis and release growth factors.
Redness, warmth, mild swelling and tenderness may occur.
Inflammation initiates and supports the repair process.

Important: Increasing pain, spreading redness, worsening swelling, purulent drainage or systemic deterioration may indicate infection or another complication and require clinical assessment.

3. Proliferative Phase

Fibroblasts produce extracellular matrix and collagen.
Angiogenesis forms new blood vessels.
Granulation tissue develops.
Epithelial cells migrate to cover the wound surface.
Wound contraction may reduce wound size.

Granulation Tissue: Healthy granulation tissue is often moist, pink to red and granular in appearance. It contains new capillaries, fibroblasts and extracellular matrix.

4. Remodeling or Maturation Phase

Collagen is reorganized and remodeled.
The scar gradually becomes stronger.
Vascularity generally decreases as the scar matures.
Tensile strength improves over time but usually does not return to the strength of uninjured skin.
Remodeling may continue for months or longer.

9. Types of Wound Healing by Intention

A. Primary Intention

The wound edges are brought together, usually by sutures, staples or adhesive. There is minimal tissue loss, and healing generally occurs with less granulation tissue and a smaller scar.

Example: A clean surgical incision closed primarily.

B. Secondary Intention

The wound is left open and heals from the bottom upward through granulation tissue formation, contraction and epithelialization. It usually takes longer and may result in a larger scar.

Example: A pressure injury or an open wound with significant tissue loss.

C. Tertiary Intention (Delayed Primary Closure)

The wound is initially left open for a period of observation, contamination control or treatment. It is closed later when conditions are appropriate.

Example: Selected contaminated traumatic wounds that are closed after reassessment and management.

Feature	Primary	Secondary	Tertiary
Wound edges	Approximated	Remain open	Closed later
Tissue loss	Usually minimal	Often greater	Variable
Granulation	Less	More	Depends on wound condition
Healing time	Usually shorter	Usually longer	Delayed closure followed by healing
Scar	Usually smaller	May be larger	Variable

10. Factors Affecting Wound Healing

A. Local Factors

Infection or high microbial burden
Poor local blood supply
Low oxygen availability
Foreign bodies or retained debris
Necrotic tissue
Excessive pressure or repeated trauma
Edema
Excessive wound tension
Wound size, depth and location

B. Systemic Factors

Factor	Effect on Healing
Diabetes mellitus	May impair circulation, immune function and tissue repair, especially when poorly controlled.
Malnutrition	Insufficient energy, protein and micronutrients may delay tissue repair.
Older age	Healing may be slower due to associated physiological changes and comorbidities.
Smoking	Reduces tissue oxygenation and is associated with impaired healing.
Anemia	May reduce oxygen delivery to tissues.
Immunosuppression	May impair infection control and tissue repair.
Corticosteroids	May suppress inflammatory responses and delay aspects of healing.
Dehydration	May compromise circulation and overall physiological recovery.

Nursing Focus: Support adequate nutrition and hydration, manage comorbidities, protect the wound from trauma, reduce pressure, and monitor for infection.

11. Complications of Wound Healing

1. Wound Infection

Microorganisms invade or proliferate in the wound and may impair healing.

Increasing or spreading redness
Increasing warmth or swelling
Worsening pain
Purulent drainage
Delayed healing
Fever or systemic deterioration in more severe cases

2. Wound Dehiscence

Partial or complete separation of previously closed wound edges. It may occur due to infection, increased tension, poor healing or other patient-related factors.

3. Evisceration

Protrusion of internal organs or tissue through a separated surgical wound. This is a surgical emergency.

🚨 Nursing Emergency – Evisceration

Stay with the patient and call for immediate surgical assistance.
Position the patient to reduce tension on the abdominal incision, as clinically appropriate.
Cover exposed organs with sterile saline-moistened dressings according to emergency protocol.
Do not attempt to push organs back into the abdomen.
Monitor vital signs and prepare for urgent management.

4. Hematoma

A collection of blood within tissue that may cause swelling, pain or pressure and may interfere with healing.

5. Seroma

A collection of serous fluid in tissue spaces, sometimes occurring after surgery.

6. Hypertrophic Scar

Raised scar tissue that remains within the boundaries of the original wound.

7. Keloid

Excessive scar tissue that extends beyond the original wound boundaries.

8. Chronic Non-Healing Wound

A wound that fails to progress through expected healing stages, often due to multiple local and systemic factors.

12. Wound Assessment

A systematic wound assessment helps identify healing progress, complications and the need for changes in care.

Assessment Area	What to Assess
Location	Exact anatomical site.
Length, width and depth	Measure consistently according to facility protocol.
Wound bed	Granulation, epithelial tissue, slough or necrotic tissue.
Wound edges	Approximated, rolled, macerated or separated.
Exudate	Amount, color, consistency and odor after cleansing when appropriate.
Periwound skin	Redness, warmth, maceration, edema or breakdown.
Pain	Severity, pattern and changes from previous assessment.
Signs of infection	Increasing pain, spreading redness, purulence, fever or systemic changes.
Healing progress	Compare measurements and wound characteristics over time.

Documentation Tip: Record objective findings and use consistent measurement methods. Follow facility policy for photography, consent and wound documentation.

13. Nursing Management of Wounds

A. Assessment and Monitoring

Assess wound location, dimensions, tissue type and drainage.
Monitor vital signs when infection or systemic illness is suspected.
Assess pain before, during and after wound care.
Review diabetes, vascular disease, nutrition and other healing risks.
Monitor wound changes and report deterioration promptly.

B. Wound Care

Perform hand hygiene before and after wound care.
Use appropriate aseptic or clean technique according to wound type and institutional protocol.
Use prescribed wound cleansing solutions and dressings.
Protect surrounding skin from excess moisture and adhesive injury.
Maintain an appropriate wound environment as indicated.
Administer prescribed analgesia when appropriate.
Follow orders and scope of practice for debridement or advanced wound therapies.

C. Nutrition and Hydration

Encourage adequate energy and protein intake according to individual needs.
Promote a balanced diet with appropriate vitamins and minerals.
Assess for malnutrition and refer to a dietitian when indicated.
Encourage appropriate hydration unless fluid restriction is prescribed.
Support blood glucose management in patients with diabetes.

D. Patient Education

Explain wound care and dressing instructions.
Teach hand hygiene before wound contact.
Advise patients not to remove or change dressings contrary to instructions.
Explain warning signs of infection or wound separation.
Encourage smoking cessation and management of underlying disease.
Reinforce follow-up appointments.

14. Wound Dressing Principles

Verify the wound-care order and identify the patient.
Explain the procedure and provide privacy.
Perform hand hygiene and use appropriate PPE.
Assess pain and provide prescribed pain relief when indicated.
Remove the old dressing carefully, observing drainage and wound condition.
Dispose of contaminated materials safely.
Assess and cleanse the wound according to the prescribed plan.
Apply the appropriate dressing using the required technique.
Secure the dressing without excessive pressure.
Document wound findings, dressing used and patient response.

Important: Dressing selection depends on wound depth, exudate, tissue condition, infection status and the treatment plan. No single dressing is appropriate for every wound.

15. Pressure Injury Prevention

Pressure injuries are localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical device. They may occur due to pressure or pressure combined with shear.

Preventive Nursing Measures

Assess pressure injury risk using an appropriate validated tool.
Inspect the skin regularly, especially over bony prominences.
Reposition according to the patient's condition, risk and support surface.
Use pressure-redistributing mattresses or cushions when indicated.
Manage moisture and incontinence-associated skin damage.
Support adequate nutrition and hydration.
Offload heels and other vulnerable areas as appropriate.
Educate patients and caregivers about skin protection.

Clinical Note: Repositioning schedules should be individualized according to skin condition, mobility, clinical status and support surface. A single fixed interval is not suitable for every patient.

16. Possible Nursing Diagnoses

Select diagnoses according to the patient's assessment findings and the current nursing diagnosis framework used by your institution.

Acute Pain related to tissue injury or wound inflammation.
Impaired Skin Integrity related to disruption of epidermis or dermis.
Impaired Tissue Integrity when deeper tissue structures are involved.
Risk for Infection related to disruption of protective skin barrier.
Impaired Physical Mobility when pain or wound location limits movement.
Deficient Knowledge related to wound care or prevention, when identified.

17. NORCET High-Yield Points

Inflammation is a protective response to injury or harmful stimuli.
Rubor = redness.
Calor = heat.
Tumor = swelling.
Dolor = pain.
Functio laesa = loss of function.
Neutrophils are prominent early in acute inflammation.
Macrophages are important in phagocytosis and repair signaling.
Histamine promotes vasodilation and vascular permeability.
Hemostasis begins immediately after injury.
Fibroblasts produce collagen and extracellular matrix.
Angiogenesis means formation of new blood vessels.
Granulation tissue is associated with the proliferative phase.
Remodeling may continue for months or longer.
Primary intention involves approximated wound edges.
Secondary intention involves an open wound healing by granulation and contraction.
Tertiary intention means delayed primary closure.
Keloid extends beyond the original wound boundary.
Hypertrophic scar remains within the original wound boundary.
Evisceration is a surgical emergency.
Diabetes, smoking, infection and malnutrition may delay healing.

18. Quick Revision

Concept	Key Point
Acute inflammation	Rapid response; neutrophils predominate early.
Chronic inflammation	Prolonged response; macrophages and lymphocytes are important.
Hemostasis	Platelet plug and fibrin clot.
Inflammatory phase	Phagocytosis and removal of debris.
Proliferative phase	Granulation tissue, angiogenesis, collagen deposition and epithelialization.
Remodeling phase	Collagen reorganization and increasing tensile strength.
Primary intention	Wound edges approximated.
Secondary intention	Wound remains open; granulation and contraction.
Tertiary intention	Delayed primary closure.
Keloid	Scar extends beyond original wound.
Evisceration	Urgent surgical emergency.

19. Frequently Asked Questions

What are the five cardinal signs of inflammation?

Redness, heat, swelling, pain and loss of function.

Which cells predominate early in acute inflammation?

Neutrophils are usually the predominant early leukocytes.

What is granulation tissue?

New vascular connective tissue containing capillaries, fibroblasts and extracellular matrix that develops during wound repair.

What is the difference between primary and secondary intention?

Primary intention involves approximated wound edges. Secondary intention involves an open wound that fills with granulation tissue and contracts during healing.

What is the difference between a keloid and a hypertrophic scar?

A keloid extends beyond the original wound boundary, whereas a hypertrophic scar remains within it.

What should a nurse do if evisceration occurs?

Call for immediate surgical assistance, protect exposed tissue with sterile saline-moistened dressings according to protocol, avoid replacing the organs and prepare for urgent management.

UNITY MEDICAL ACADEMY

📝 MCQ PRACTICE TEST

Inflammation and Wound Healing

25 Questions | 25 Marks | 30 Minutes

Clinical Concepts • Nursing Application • NORCET Level

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Nursing Foundation - Inflammation And Wound Healings Notes With MCQs Practice