Infection, inflammation and immunity
Primary prevention against an infection includes ____ and ____
Vaccinations and hygiene
a nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?
a client who has swelling and tenderness around the wound
Ringworm is caused by
a fungus
What is an example of a primary defense that protects the body from infection?
a. Antibiotic therapy b. The high pH of the skin c. Cilia in the respiratory tract d. The alkaline environment of the vagina
A patient has sustained a severe right ankle sprain, and the nurse is explaining the process of inflammation to the patient and family. Which information does the nurse include in this teaching?
a. Because inflammation is present, treatment for infection is advised. b. The inflammation response is painful but provides long-term protection. c. Inflammation is a specific body defense in response to the ankle injury. d. Symptoms of localized inflammation are contained to the area of injury
The phases of wound healing include:
Inflammatory Proliferative Remodeling maturation
What is the portal of exit?
Is when an infectious agent leaves from the reservoir. It leaves from skin, urinary tract, mucous membrane, blood and even respiratory tract. Once it leaves it must be transmitted from one host to another.
Ask about ____ and ____ with those who may have an infection
exposure and pain
a diet for patients with infection?
high protein
a nurse is reinforcing teaching with a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?
increase fluid intake by drinking bottled water
vasodilation:
increased blood flow to the area
IgD means:
is on the surface of developing B lymphocytes
what factors can make someone susceptible to infection?
- stress - nutrition -fatigue -age -medical diseases
what are the 5 major classes of immunoglobulin?
-IgG, IgA, IgM, IgD, IgE
what is the purpose of vasodilation for inflammation?
-brings white blood cells to area -supplies nutrients and oxygen for energy -dilute any toxins and minimize their damage
How to protect the host from infection ?
1) hand washing 2) regular hygiene 3) oral hygiene 4) proper sleep and rest 5) well nourished and hydrated 6) immunizations
What are the phases of the inflammatory response?
1) vascular changes 2) cellular changes 3) tissue repair
how much fluid is required by patients with infection?
2 liters a day
Normal white blood cell count (WBC):
4.5-11 (4500-11,000)
A patient has researched bradykinin on the Internet. Which information indicates the patient understands the functions of bradykinin? Bradykinin is involved in:
Increasing vascular permeability
What is the host in the chain of infection?
Its a source that provides shelter and nourishment for pathogens.
Radiographic tests for inflammation include:
MRI, CAT scan, pet scan, colonoscopy
What is the illness phase?
Patient has their symptoms for example fever, cough, sneezing, body ache are specific to the disease. If a patient has gastroenteritis then the patient will have an upset stomach cramps, nausea, vomiting and diarrhea as their symptoms.
What happens during the maturation phase?
The final stage of healing begins about 3 weeks after the injury, possibly continuing for months or years. Collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger and more like adjacent tissue.
Individual risk factors for infection include:
immunodeficiency chronic disease crowded or unsanitary living conditions contaminated water/air improper food storage or prep breaks in their skin lack of proper nutrition smokers medications (steroids) multiple sex partners stress
IgA means:
immunoglobulin in body secretions
what is chronic inflammation?-why does it often occur?
inflammation that persists for weeks to months after initial tissue injury. It's pathological features include simultaneous tissue repair and destruction. -often occurs bc a chronic persistence of tissue injury and acute inflammation
What happens during the incubation period?
is when the pathogen first gets in the body until it starts to make its appearance known. when pathogen is multiplying inside your body.
How does fatigue affect the immune system?
it can decrease ones energy and strength
What is a pathogen?
its an infectious agent, an organism that is capable of producing a disease, viruses, bacteria, fungus, yeast, mold, protozoa and parasites.
What happens during the prodromal period?
its the starting of initial symptoms but the symptoms are vague and specific. For example the patient can't describe what's wrong with them and might just stay they aren't feel well or feel weak.
IgM means
largest immunoglobulin. it is the first immunoglobulin produced during the initial response to an antigen.
a nurse is caring for a client who has a respiratory infection. When the client asked how the position the nurse put him and can help, the nurse should explain that lying on his left side in Trendelenburg position helps mobilize secretions from which of the following lug segments?
lateral segment of right lower lobe
what is the secondary intention of healing?
more tissue loss requiring epithelialization, scar formation, and contraction
A hormone produced by the adrenal cortex that is anti-inflammatory is?
neutrophils
What happens during the hemostasis phase?
occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering.
what is the primary intention of healing?
primary: wounds that heal under minimal tissue loss
IgE means:
principle immunoglobulin in allergic responses and in prevention of parasitic infections (eosonphils have a very similar function)
a nurse is reinforcing discharge teaching with a client who is immunocompromised. Which of the following instruction should the nurse include in the teaching?
restrict visitors with active infections, instruct the client to eat cooked Foods only
Normal flora are microorganisms found within the body such as from
saliva, mucous membranes, GI tract and skin. they help protect the body from pathogens and they are protective as long as they are in their own environment.
a nurse is caring for a client who has acute osteomyelitis. The client asks the nurse to explain how she developed infection. The nurse should respond that which of the following organisms is the most common cause?
staphylococcus aureus
How does stress affect the immune system?
stress weakens the immune system and it can't fight the infection as affectively.
convalescence stage is when......
symptoms start to disappear until the patient is fully healed for example a pt with a cold starts to get better in a couple of days.
many childhood illnesses such as measles are caused by
viruses
which is a sign of local infection?
warm skin
How does age affect the immune system?
when your'e young and old, the immunity is weak. In the young the immune system has developed effectively. In the old the immune system doesn't function as it used to and risk of infection increases.
What is the portal of entry?
where an organism enters a new host and breaks into the skin by being ingested or by being inhaled.
What is a reservoir?
where pathogens live in reservoir. Environment is important for their survival but if they are taken out of their environment they will die. An organism grows and multiplies during this phase.
what are some underlying medical conditions that can have an affect on the immune system?
Diabetes, HIV, cancer, chemotherapy, autoimmune disorders, organ transplant and more
which of the following should the nurse recognize as a sign of possible infection and a post-operative client?
adventitious breath sounds, decreased level of Consciousness, oral temperature of 101 Fahrenheit
a nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection?
an increase in neutrophils, localized edema
a nurse is caring for a preschooler who has epiglottitis from streptococcus infection. Which of the following actions should the nurse take?
apply humidified oxygen via mask because this will help decrease inflammation and prevent hypoxia
How does nutrition affect the immune system?
being malnourishment can have an increase risk of infection on the patient. - well balanced diet -take vitamins and minerals to boost immunity
droplet transmission
can occur from coughing, sneezing, talking, respiratory droplets. large particles travel less distance and fall about 3 feet. infects people from going into the eyes, nose and mouth. diseases: flu, pneumonia, rubella, influenza and more.
The body's first line of defense:
defense: Skin and mucous membranes
a nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect?
dysuria, urinary frequency, hematuria
IgG means:
80-85% of circulating immunoglobulin--able to cross the placenta
Laboratory tests for inflammation include:
CBC, WBC with diff, CRP, ESR, Serologic (tests to detect specific antibodies or viruses)
A 5-year-old female takes a hike through the woods during a school field trip. Upon returning home, she hugs her father, and he later develops poison ivy. Which of the following immune reactions is he experiencing?
Cell-mediated
Look for these things with infection:
Fever Malaise Fatigue Chills
What happens during the proliferation phase?
The proliferation phase lasts for several weeks. New tissue is built to fill the wound space, primarily through the action of fibroblasts.
airborne transmission
The spread of an organism via coughing, sneezing, respiratory droplets. example: chicken pox, shingles, measles and tuberculosis particles so small and stay in the air.
What is the mode of transmission?
When the pathogen spreads either from air, droplet or contact and how it gets from one place to another.
phagocytosis:
White blood cells "eat" bacteria that can cause infection when they invade the body
what happens during the inflammatory phase?
White blood cells, predominantly leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages enter the wound area and remain for and extended period.
Radiographic tests for infection include:
X-Ray, MRI, cat scan, pet scan and indium scans
Which patients have factors that may affect the function of the immune system? Select all that apply.
a. Patient has been on a severely limited diet for several weeks to quickly lose weight. b. Patient is homeless and is continuously seeking shelter for cold weather conditions. c. Patient is on multiple medications for an auto immune disorder. d. Patient is a 30-year-old adult with a family history of hypertension and high cholesterol. e. Patient is 84 years old and lives alone in her own house. f. Patient has type 2 diabetes mellitus that is well controlled with oral antidiabetic medication
a nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
cleanse the world was 0.9% sodium chloride irrigation before obtaining the specimen
a nurse is caring for a client who has a wound infection that contains VRE. Which of the following types of precautions should the nurse plan to take while caring for this client?
contact
What is the prodromal period?
early and subtle signs and symptoms of infection; most infectious stage of infection process; pathogens are multiplying rapidly
a nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?
edema
people with generalized infection become dehydrated because of?
fever and anorexia
What is the incubation period?
first phase of infection process; Interval between infection and development of symptoms; infection is growing
convalescence
full recovery, gradual return to health and strength after an illness or other problem