Med-Surg 1 Inflammation and Healing

Place the following events that occur during healing by primary intention in sequential order from 1 (first) to 10 (last)? a. Blood clots for b. Approximation of wound edges c. Avascular, pale, mature scar present d. Enzymes from neutrophils digest fibrin e. .Epithelial cells migrate across wound surface f. Fibroblasts migrate to site and secrete collagen g. Budding capillaries result in pink, vascular friable wound h. Healing area contracts by movement of myofibroblasts i. Macrophages ingest and digest cellular debris and red blood cells j. Fibrin clot serves as meshwork for capillary growth and epithelial cell migration

a. 2; b. 1; c. 10; d. 4; e. 8; f. 6; g. 7; h. 9; i. 3; j. 5

2. What type of dressing will the nurse most likely use for the patient in the previous question? a. Hydrocolloid b. Transparent film c. Absorptive dressing d. Negative pressure wound therapy

a. A clean wound would be treated with a hydrocolloid or hydrogel dressing because they provide a moist environment to encourage granulation. Transparent film would be likely to result in further tissue loss. There would not be enough drainage for an absorptive dressing unless this pressure injury became infected. An eschar wound may be treated with autolytic debridement and then negative pressure wound therapy, depending on the depth and healing of the wound.

Which patient is at the greatest risk for developing a pressure injury. a. A 42-year-old obese woman with type 2 diabetes b. A 78-year-old man who is confused and malnourished c. A 30-year-old man who is comatose after a head injury d. A 65-year-old woman who has urge and stress incontinence

12. c. The immobility, mental deterioration, and possible neurologic disorder of the comatose patient present th greatest risk for tissue damage related to pressure. Braden score is 9, which puts him at very high risk Is Although obesity, hyperglycemia, advanced age, deterioration, malnutrition, and incontinence contribute development of pressure injuries, the risk is not as high.

During the healing phase of inflammation, which cells would be most likely to regenerate? a. Skin b. Neurons c. Cardiac muscle Skeletal muscle

a. Labile cells of the skin, lymphoid organs, bone marrow, and mucous membranes divide constantly and regenerate rapidly following injury. Stable cells, such as those in bone, liver, pancreas, and kidney, regenerate slowly only if they are injured. Axons in the CNS are generally less successful at regeneration than peripheral axons. There may be a certain amount of recovery after injury involving the neurons. Cardiac muscle is not expected to regenerate but will scar when damaged.

A patient who had abdominal surgery 3 months ago calls the clinic reporting severe abdominal pain and cramping, vomiting, and bloating. What should the nurse most likely suspect as the cause of the patient's problem? a. Infection b. Adhesion c. Contracture d. Evisceration

b. Adhesion is a band of scar tissue that forms between organs. It may occur in the abdominal cavity and cause intestinal obstruction. Infection could be seen with undernutrition or necrotic tissue but would not cause these symptoms. Contractures shorten the muscle or scar tissue but would not contribute to abdominal symptoms. Evisceration of an abdominal wound would occur sooner after surgery when the wound edges separate and the intestines protrude through the wound.

Priority Decision: What is the most important nursing intervention for the prevention and treatment of pressure injuries? a. Using pressure-reduction devices b. Repositioning the patient frequently c. Massaging pressure areas with lotion d. Using lift sheets and trapeze bars to facilitate patient movement

b. Relief of pressure on tissues is critical to prevention and treatment of pressure injuries. Although pressure_ reduction devices may relieve some pressure and lift sheets and trapeze bars prevent skin shear, they are no substitute for frequent repositioning individualized for the patient Massage is contraindicated if there is the presence of inflammation or possibly damaged blood vessels or fragile skin.

What is characteristic of chronic inflammation? a. It may last 2 to 3 weeks. b. The injurious agent persists or repeatedly injures tissue. c. Infective endocarditis is an example of chronic inflammation. d. Neutrophils are the predominant cell type at the site of inflammation.

b. The injurious agent of chronic inflammation persists or repeatedly injures tissue. It lasts for weeks, months, or years. Infective endocarditis is a subacute inflammation that lasts for weeks or months. Neutrophils are the predominant cell type in acute inflammation. Lymphocytes and macrophages are the predominant cell types at chronic inflammation sites.

Collaboration: Which nursing interventions for a patient with a stage 4 sacral pressure injury are most appropriate to assign or delegate to a licensed practical/vocational nurse (LPN/VN) (select all that apply)? a. Assess and document wound appearance. b. Teach the patient pressure injury risk factors. c. Assist the patient to change positions at frequent intervals. d. Choose the type of dressing to apply to the pressure injury. e. Measure the size (width, length, depth) of the pressure injury.

c, e. Measuring the size of the wound and repositioning do not require judgment, patient teaching, or evaluation of care. The other interventions listed relate to assessment, judgment, and teaching, all of which are responsibilities of the RN. However, the LPN can reinforce teaching by the RN. The unlicensed assistive personnel (UAP) may also be able to help with repositioning, if delegated by the RN.

Which nutrients aid in capillary synthesis and collagen production by the fibroblasts in wound healing? a. Fats b. Proteins c. Vitamin C d. Vitamin A

c. . Vitamin C aids healing with capillary synthesis and collagen production by fibroblasts. Fats provide synthesis of fatty acids and triglycerides used for cellular membranes. Protein corrects negative nitrogen balance from increased metabolism and contributes to synthesis of immune factors, blood cells, fibroblasts, and collagen. Vitamin A aids in epithelialization, increasing collagen synthesis, and tensile strength of the healing wound.

What does the mechanism of chemotaxis accomplish? a. Causes the transformation of monocytes into macrophages b. Involves a pathway of chemical processes resulting in cellular lysis c. Attracts the accumulation of neutrophils and monocytes to an area of injury d. Slows the blood flow in a damaged area, allowing migration of leukocytes into tissue

c. Chemotaxis involves the release of chemicals at the site of tissue injury that attract neutrophils and monocytes to the site of injury. When monocytes move from the blood into tissue, they are transformed into macrophages. The complement system is a pathway of chemical processes that results in cellular lysis, vasodilation, and increased capillary permeability causing the slowing of blood flow at the area. Prostaglandins slow blood flow to allow for clot formation at the injury.

The patient's wound is not healing, so the health care provider (HCP) is going to send the patient home with negative pressure wound therapy. What will the caregiver need to understand about the use of this device? a. The wound must be cleaned daily. b. The patient will be placed in a hyperbaric chamber. c. The occlusive dressing must be sealed tightly to the skin. d. The diet will not be as important with this sort of treatment.

c. For the negative pressure therapy to work, a vacuum is created between the device and the wound so that the excess fluid, bacteria, and debris are removed from the wound. The wound is cleaned weekly or when the dressing is replaced. A hyperbaric oxygen therapy chamber is not used with a negative pressure device. Nutrition must be maintained, as protein and electrolytes may be removed from the wound.

A patient's documentation indicates he has a stage 3 pressure injury on his right hip. What should the nurse expect to find on assessment of the patient's right hip? a. Exposed bone, tendon, or muscle b. An abrasion, blister, or shallow crater c. Deep crater through subcutaneous tissue to fascia d. Persistent redness (or bluish color in darker skin tones)

c. Stage 3 is full-thickness tissue loss; subcutaneous fat may be visible. Bone, tendon, and muscle are exposed in a stage 4 pressure injury. Abrasion, blister, and shallow crater are seen in stage 2 pressure injuries. Persistent redness or discoloration of darker skin tones describes a stage I pressure injury.

Priority Decision: Key interventions for treating initial soft tissue injury and resulting inflammation are remembered using the acronym RICE. What are the most important actions for the emergency department nurse to do for the patient with an ankle injury? a. Reduce swelling, shine light on wound, control mobility, and get the history of the injury. b. Rub the wound clean, immobilize the area, cover the area protectively, and exercise the leg. c. Rest with immobility, apply a cold compress and/or a compression bandage, and elevate the ankle. d. Rinse the wounded ankle, get x-rays of the ankle, carry the patient, and extend the ankle with a splint.

c. The nurse will encourage Rest and Immobility to prevent further injury. Ice or cold Compresses will be applied to decrease swelling with vasoconstriction. Compression will help reduce edema and stop bleeding if it is occurring. Elevation will help decrease edema and pain. The other options are not correct.

What is the primary difference between healing by primary intention and healing by secondary intention? a. Primary healing requires surgical debridement for healing to occur. b. Primary healing involves suturing 2 layers of granulation tissue together. c. Presence of more granulation tissue in secondary healing results in a larger scar. d. Healing by secondary intention takes longer because more steps in the healing process are necessary.

c. The process of healing by secondary intention is essentially the same as primary healing. With the greater defect and gaping wound edges of an open wound, healing and granulation take place from the edges inward and from the bottom of the wound up, resulting in more granulation tissue and a much larger scar. Secondary healing may require surgical debridement for healing to occur. In primary healing, the edges of the wound are aligned and may be sutured. Tertiary healing involves delayed suturing of 2 layers of granulation tissue together and may require debridement of necrotic tissue.

The patient is admitted from home with a clean stage 2 pressure injury. What does the nurse expect to observe when doing a wound assessment? a. Adherent gray necrotic tissue b. Clean, moist granulating tissue c. Red-pink wound bed, without slough d. Creamy ivory to yellow-green exudate

c. The stage 2 pressure injury is a shallow, partial thickness wound with a red-pink wound bed, without slough. Adherent gray necrotic tissue describes eschar tissue, which cannot be staged. Clean, moist granulating tissue occurs over time as the wound heals. Creamy exudate occurs when the wound is contaminated or infected, regardless of the stage of the pressure injury.

A patient had a complicated vaginal hysterectomy. The student nurse provided perineal care after the patient had a bowel movement. The student nurse tells the nurse there was a lot of light-brown, smelly drainage seeping from the vaginal area. What should the nurse suspect when assessing this patient? a. Dehiscence b. Hemorrhage c. Keloid formation d. Fistula formation

d. A fistula is an abnormal passage between organs or between a hollow organ and skin that will leak fluid or pus until it is healed. In this situation, there may be a fistula between the vagina and rectum. The student nurse did not describe dehiscence, hemorrhage, or keloid scar formation.

In a patient with leukocytosis with a shift to the left, what does the nurse recognize as causing this finding? a. The complement system has been activated to enhance phagocytosis. b. Monocytes are released into the blood in larger-than-normal amounts. c. The response to cellular injury is not adequate to remove damaged tissue and promote healing. d. The demand for neutrophils causes the release of immature neutrophils from the bone marrow.

d. A shift to the left is the term used to describe the presence of immature, banded neutrophils in the blood in response to an increased demand for neutrophils during tissue injury. Monocytes are increased in leukocytosis but are mature cells.

Priority Decision: During care of patients, what is the most important precaution for preventing transmission of infections? a. Wearing face and eye protection during routine daily care of the patient b. Wearing nonsterile gloves when in contact with body fluids, excretions, and contaminated items c. Wearing a gown to protect the skin and clothing during patient care activities likely to soil clothing d. Hand washing after touching fluids and secretions, removing gloves, and between patient contacts

d. Hand washing is the most important factor in preventing infection transmission and is recommended before and after the use of gloves by the Centers for Disease Control and Prevention for all types of isolation precautions in health care facilities.

The patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure injury does the nurse expect to see on admission? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

d. Stage 4 pressure injuries are full-thickness tissue loss with muscle, tendon, or bone exposed. Stage I pressure injuries are intact skin with nonblanchable localized redness. Stage 2 pressure injuries have a shallow open area with a red-pink wound bed. Stage 3 pressure injuries exhibit full-thickness tissue loss without bone tendon, or muscle exposure with possible tunneling into the tissue.

What role do the B-complex vitamins play in wound healing? a. Decrease metabolism b. Protect protein from being used for energy c. Provide metabolic energy for the inflammatory process d. Coenzymes for fat, protein, and carbohydrate metabolism

d. The B-complex vitamins are necessary coenzymes for many metabolic reactions, including protein, fat, and carbohydrate metabolism. Carbohydrates provide metabolic energy for inflammation and are protein sparing. Fluid is needed to replace that used in exudates as well as the extra fluid used for the increased metabolic rate required for healing.

What effect does the action of the complement system have on inflammation? a. Modifies the inflammatory response to prevent stimulation of pain b. Increases body temperature, resulting in destruction of microorganisms c. Produces prostaglandins and leukotrienes that increase blood flow, edema, and pain d. Increases inflammatory responses of vascular permeability, chemotaxis, and phagocytosis

d. The processes that are stimulated by the activation of the complement system include enhanced phagocytosis, increased vascular permeability, chemotaxis, and cellular lysis. Prostaglandins and leukotrienes are released by damaged cells, and body temperature is increased by the action of prostaglandins and interleukins. All chemical mediators of inflammation increase the inflammatory response and, as a result, increase pain.