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Nordqvist, C. (2017). Everything you need
to know about inflammation. Medical News Today.

National Institute of Medicine. (2015).
What is inflammation? Retrieved from

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Moores, J. (2014). Vitamin C: a wound
healing perspective. Wound Care.

Mohammad, B. M., Fisher, B. J., Kraskauskas,
D., Ward, S., Wayne, J. S., Brophy, D. F., Fowler III, A. A., Yager, D. R., &
Natarajan, R. (2016). Vitamin C promotes wound healing through novel pleiotropic mechanisms. Internal Wound Journal 13(4).

Medline Plus. (2017). Immune Response.
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Jaffe, L. & Wu, S. (2017). The Role
of Nutrition in Chronic Wound Care Management. Podiatry Management.

Grossman, S. C. & Porth, C. M. (2014).
Porth’s Pathophysiology (9th ed.)
Wolters Kluwer Health/Lippincott Williams & Williams.


            In this case, initial
injury occurred when the patient cut his foot on a shell.  Further
injury occurred when the open wound was introduced to contaminated water.  The physical barrier was broken, allowing for
multiple pathogens to cause an innate immune response.  As a result, the increased blood flow to the
area of injury into surrounding capillaries cause redness, warmth and swelling to the area. 
Swelling to the area helps to
protect surrounding tissues from coming into contact with infectious
agents.  The immune system send T and B lymphocytes to the area to aid in
the attack of infectious agents.  Wound
healing occurs in multiple phases, with adequate nutrition playing a crucial
role during the proliferative phase of healing. 
Proper wound healing is dependent upon the intact and stores of vitamin
A and vitamin C.

            In order for tissue repair to happen, there needs to an
active participation of the following cells: leukocytes, macrophages,
connective tissue cells, epithelial cells, myofibroblasts, which help the
epithelial cells to cover the damaged portion of the foot, angioblasts, which
are the beginning of blood vessels, fibroblasts, which are responsible for the
production of the extracelluar matrix, fibronectin, which is the glue which
holds cells together, and collagen which helps to form fibrin strands providing
for strength to the area (National Institute of Health, 2016). In order for
wound healing to be successful, the body needs to have adequate reserves of
proteins, carbohydrates, fats, and vitamins. Both vitamins A and C are
essential during the proliferative stage of wound healing.  The proliferative stage of healing is focused
primarily on the composition of new tissue to fill a wound space.   Fibroblasts produce a familial growth factor which
is responsible for the induction of angiogenesis and endothelial cell
proliferation and migration (Grossman & Porth, 2014).  Vitamin A and C play a major part in the
healing process.  Vitamin C is needed for
collagen synthesis.  If there is a
deficiency of vitamin C, there is an improper sequencing of amino acids and the
successful linking of those amino acids cannot occur.  A wound will not heal properly as a result of
the derivatives of collagen synthesis not being removed from the old cell
structure.  Vitamin A is needed for wound
healing to stimulate and support the epithelialization, formation of
capillaries, and collagen synthesis. 
According to Jaffe & Wu, 2017, nutrients which are rich in Vitamins
A, C, and E help to augment wound healing. 
Vitamin A is beneficial in the
support of collagen desposition within
the wound.  Vitamin C is perhaps, the
most critical nutrient in wound healing. 
The fibroblasts are reliant upon vitamin C for collagen production.  While vitamin C is crucial in the proliferative
stage of wound healing, it is needed for all stages of proper wound healing.  A vitamin C deficiency plays part in the
maturation phase of healing and affects proper scar formation (Moores,
2014).  Primarily, vitamin C promotes the
healing of wounds by the alteration of inflammation, as well as the
proliferative and remodeling stages of wound healing.  Vitamin C helps to suppress the
pro-inflammatory response, while
promoting anti-inflammatory and pro-resolution effect (Mohammed, Fisher,
Kraskauskas, Ward, Wayne, Brophy, Fowler III, Yager & Natarajan, 2016).

            In the sense of immunological events which are taking
place at a local level during the acute inflammatory response, white blood
cells (WBCs), which are also inclusive of chemicals, proteins, such as
antibodies, interferon and complement proteins were activated.  Lymphocytes, which are a type of WBC are
composed of B and T lymphocytes.  The B
lymphocytes are the cells which produce the antibodies to the infectious
agent.  The antibodies are able to attach
themselves to specific agents making it easier for the immune system to destroy
infectious antigens.  T lymphocytes are
responsible for attacking the antigen directly and helping to control immune
responses.  T lymphocytes are also responsible
for the release of cytokines (Medline Plus, 2017).  When Carlton stepped on the shell and cut his
foot, there was a disruption in homeostasis of the immune system.  The injury to foot disrupted the immune system
and caused the development of systemic inflammatory response syndrome, or SIRS,
as well as the compensatory anti-inflammatory response syndrome, or CARS.  Soon after the injury, inflammasomes are
activated and toll-like receptors are also activated in macrophages at the same
time that T cells are readied (Osuka, Ogura, Ueyama, Shimazu, & Lederer,

            In order for germs to be able to cause inflammation,
there should be a portal of entry for the pathogen.  The term portal of entry refers to any
process in which the pathogen gains entrance into the host’s body.  In this patient’s case, the portal of entry
was caused from penetration of the skin
by the sea shell.  Other portals of entry
include direct contact, inhalation, or ingestion.  The cut which was caused by the sea shell
altered the patient’s surface barrier (the skin), and allowed for a portal of
entry for a pathogen(s) to enter the body (Grossman & Porth, 2014).  From a physiological stand point, redness,
heat, swelling, pain and loss of function are all common indications of inflammation.  Pain is caused when chemicals which stimulate
the nerve ending are released, thus making the area painful.  Redness occurs to the affected area when
blood capillaries in the immediate area become engorged with more blood than
usual.  Swelling is caused from a
build-up of fluid in the affected area. 
When there is an increased blood flow to the area, the area feels warm
to touch (Nordqvist, 2017).  Skin which
is intact is the most powerful barrier against infection.  The physical barrier of intact skin is composed of cells which are
closely packed together and are formed in multiple layers.  When there is a break in the defense system,
the complement system is activated.  Germs
which are able to overcome the protective barrier of the skin, create an innate
immune response, or a nonspecific immunity which is a part of the immune system
that is intact upon birth. Hemodynamic changes are the body’s first response to
injury.  Stimuli causes nerves which
transmit signals to the smooth muscle cells. 
The smooth muscle cells then act as sphincters which regulate the blood
flow to the capillaries.  When the smooth
muscle relaxes, this allows for the increase of blood flow into the capillaries
causing redness, swelling, and warmth to the area.  There are many immune cells which take part
in the inflammatory process. 
Inflammatory mediators release bradykinin, which is a plasma protein
that is formed through the coagulation factor XII and histamine, which is
released from mast cells, basophils, and platelets which cause blood vessels to
expand, allowing for more blood to reach the injured area.  Inflammatory mediators also increase
permeability of vessels, allowing more defense cells to enter the area which
has been injured.  The increase of
defense cells to the injured area is what causes swelling to occur (Grossman
& Porth, 2014).  Swelling in injury
is actually beneficial as swelling or edema helps to isolate the foreign
substance from additional contact with other body tissues.  Normal immune systems defend the body against
harmful substances, sending cells to protect organs against damage from the
pathogen.  The cells release chemicals
which help to isolate and destroy the harmful substance which is attacking the
organ.  The portal of entry in which the
infectious organism gained entrance is different than in the case of

            Inflammation is the body’s immune system’s response to
stimuli.  Inflammation occurs when the
body’s immune system is attempting to fend off an organism which the body
considers as harmful.  While inflammation
may have many causes, most commonly, the causes of acute inflammation are
germs, such as bacteria or viruses, external injuries, such as is the case with
Carlton.  External injuries can be caused
by scrapes or foreign bodies. 
Inflammation can also occur as an after effect of chemicals or radiation
therapy (National Institute of Health, 2016).

            Case study four outlines the case of six-year-old
Carlton, who cut his foot while playing at the beach with his mother.  The study recalls that Carlton’s mother
washed his foot off in the lake water and took him home.  Approximately 24 hours after the initial
injury occurred, Carlton’s foot look
worse in appearance; the wound was red and inflamed, warm to touch and
painful.  Carlton was then taken to a
local community health clinic for further evaluation.



Study Four: Carlton