CH11 Inflammation

The nurse evaluates the results of antibiotic treatment that was administered to a patient with a bacterial infection. Which white blood cell (WBC) count and body temperature indicate effectiveness of the medication regimen? WBC count 4000/μL, temperature 101° F WBC count 8000/μL, temperature 101° F WBC count 8500/μL, temperature 98.4° F* WBC count 16,500/μL, temperature 98.8° F

A WBC count of 8500/μL and a temperature of 98.4° F are within the normal ranges. The normal WBC range is usually between 4000 and 11,000 per microliter of blood. The normal body temperature range is 97.6° F-99.6° F. During an infection, to keep up with the demand for neutrophils, the bone marrow releases more neutrophils into circulation. This results in a high WBC count. An elevated temperature is another indicator of infection.

The nurse reviews the medical reports of four patients and identifies that which patient may experience a blunted febrile response to infection? piroxiam

A patient with rheumatoid arthritis who is being treated with a nonsteroidal antiinflammatory drug (such as piroxicam) (Patient A) may show a blunted febrile response to infection. Prednisone is a corticosteroid and is used to treat inflammation associated with asthma (Patient B); a decreased synthesis of lymphocytes is a side effect of the drug. Chlorhexidine is an antiseptic used to clean the wound; this drug may not result in blunted febrile response (Patient C). Becaplermin is not a nonsteroidal antiinflammatory drug and does not blunt febrile response to infection (Patient D).

The nurse assesses a pressure ulcer on a patient's trochanter. The moist and pink ulcer indicates a partial-thickness loss of skin, and there is no adipose tissue present. Which pressure injury stage will the nurse document in the patient's medical record?

A stage 2 pressure injury is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist. It may present as an intact or ruptured serum-filled blister. Adipose and deeper tissues are not visible. It often results from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Characteristics of stage 1 ulcers include intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Its color may differ from the surrounding area. The area may be painful, firm, soft, and warmer or cooler as compared to adjacent tissue. Characteristics of stage 3 ulcers include full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure depth of tissue loss. It may include undermining and tunneling. The depth of a category/stage 3 pressure ulcer varies by anatomic location. Characteristics of stage 4 ulcers include full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Stage 4 often includes undermining and tunneling. The depth of pressure ulcer varies by anatomic location. Ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

A patient is admitted to a medical unit with a 104.5°F (40.3°C) temperature. Which nursing action is most effective in restoring normal body temperature? Giving the patient cold beverages Applying a cooling blanket while the patient is febrile Administering an antipyretic on an around-the-clock schedule* Providing the patient with sponge baths every two hours

Antipyretics are used to lower the body temperature and should be given around the clock to prevent acute swings in temperature. Chills may be evoked or perpetuated by the intermittent administration of antipyretics. These agents cause a sharp decrease in temperature. When the antipyretic wears off, the body may initiate a compensatory involuntary muscular contraction (i.e., chill) to raise the body temperature up to its previous level. This unpleasant side effect of antipyretic drugs can be prevented by administering the agents regularly and frequently at two- to four-hour intervals. Consuming cold beverages will not have a direct effect on lowering the body's temperature. Sponge baths and cooling blankets may not decrease the body temperature unless antipyretic drugs have been given to lower the set point. Otherwise, the body will initiate compensatory mechanisms (e.g., shivering) to restore body heat.

Which nursing assessments are the priority before a compression bandage is applied to a patient? Select all that apply. Select all that apply Distal pulses* Capillary refill* Serum protein levels Fluid and electrolytes Partial thromboplastin time

Applying a compression bandage may compromise the patient's blood circulation. Therefore the nurse should assess the distal pulses to evaluate blood circulation before and after applying a compression bandage. The nurse should check capillary refill before and after applying a compression bandage to ensure adequate blood circulation. Serum protein levels should be monitored after performing negative-pressure wound therapy. Partial thromboplastin time should be checked after performing negative-pressure wound therapy. The patient's fluids and electrolytes should be checked after applying negative-pressure wound therapy because fluid and electrolyte loss may occur.

A patient presents with a runny nose associated with an upper respiratory tract infection. Which type of inflammatory exudate does the nurse expect to assess? Purulent Fibrinous Serosanguinous Catarrha*

Catarrhal exudate is found in tissues where cells produce mucus; the inflammatory response accelerates mucus production. Purulent exudate occurs if a patient has a furuncle (boil), abscess, or cellulitis (diffuse inflammation in connective tissue). Fibrinous exudate occurs with increasing vascular permeability and fibrinogen leakage into interstitial spaces; examples include adhesions and venous injuries. Serosanguinous exudate may be found during the midpoint in healing after surgery or tissue injury; an example is surgical drain fluid.

Which type of exudate will the nurse likely observe in a patient with diffuse inflammation in connective tissue? Serous Purulent* Fibrinous Hemorrhagic

Diffuse inflammation in connective tissue is called cellulitis; this condition produces purulent exudate. Serous exudate is observed in pleural effusion. Fibrinous exudate is seen in surgical drain tubing. Hemorrhagic exudate is seen in hematoma.

As treatment for a sprained wrist, a patient receives instructions related to elevating the injured extremity above the level of the heart. The nurse questions the recommendation for elevation when discovering which history finding? Diabetes Cancer Significantly reduced arterial circulation* High-dose routine nonsteroidal antiinflammatory drug use

Elevation may be contraindicated in patients with significantly reduced arterial circulation. Elevating the injured extremity above the level of the heart is often prescribed to reduce the edema at the inflammatory site by increasing venous and lymphatic return. Elevation helps reduce pain associated with blood engorgement at the injury site. Diabetes does not cause complications due to elevation of an injured extremity. The nurse should check the patient's history for cancer and other wounds before administering becaplermin. Taking a high-dose nonsteroidal antiinflammatory drug may blunt the febrile response, but it does not cause complications while elevating an injured extremity.

The nurse assesses four patients and identifies that the patient with which condition will likely experience fibrinous inflammatory exudate? Venous ulcer* Pleural effusion Bleeding after surgery Runny nose due to laryngitis

Fibrinous exudate is observed in a patient with a venous ulcer; this exudate occurs because of increased vascular permeability and fibrinogen leakage into interstitial spaces. Hemorrhagic exudate is seen in a patient who is bleeding after surgery; this exudate is caused by a rupture of blood vessel walls. Serous exudate is seen in a patient with pleural effusion; this exudate occurs due to an outpouring of fluid. Catarrhal exudate is seen in a patient with a runny nose due to an upper respiratory tract infection (for example, laryngitis).

The nurse provides discharge education for a patient with an elbow sprain. The nurse includes information about the rest, ice, compression, and elevation (RICE) approach. Which patient statement indicates effective teaching? "I should elevate my arm, keeping it at the level of my heart." "I will apply heat 24 to 48 hours after the ice application."* "I will alternate between ice and heat as soon as I arrive at home." "I should perform some foam ball squeezes to keep my arm mobile."

Heat should be used after 24 to 48 hours (after cold application) to increase circulation to the inflamed site. Elevating the injured extremity above the level of the heart reduces the edema at the inflammatory site by increasing venous and lymphatic return. Elevation helps reduce pain associated with blood engorgement at the injury site. Cold is used immediately to promote vasoconstriction and decrease swelling, pain, and congestion at the site, followed by heat; alternating between the two is not recommended. Rest helps the body use its nutrients and oxygen for the healing process.

after soft tissue injury Provide cold application to the ankle.* Immobilize the ankle and encourage rest.* Maintain the patient in supine position with the ankle below the level of heart. Apply a compression bandage to the ankle and check the distal pulse.* Assist the patient with ambulation to prevent deep vein thrombosis (DVT).

In cases of soft tissue injuries, RICE treatment (rest, ice, compression, and elevation) is given. The affected part is immobilized and given rest. Ice or cold is applied to reduce pain and inflammation. Hot applications can be given after 24 to 48 hours. The affected part is compressed with bandages to provide support and prevent edema. The affected part should be elevated above the heart level to prevent edema and pain. Ambulating the patient would increase pain and discomfort, so it is not advisable. There is no indication that the patient is at an increased risk of DVT.

While reviewing a patient's medical record, the nurse notes a diagnosis of tuberculosis and the presence of Mycobacterium. Which physiologic change corresponds to the assessment findings? Acute inflammation Granuloma formation* Ivory to yellow-green exudate Tissue damage by complement activation

In tuberculosis, the Mycobacterium bacillus is walled off, and the macrophages accumulate and fuse to form a multinucleated giant cell that engulfs the bacterial particle . This giant cell is encapsulated by collagen and forms granuloma. Tuberculosis causes chronic inflammation. Ivory to yellow-green exudate indicates infection but is not seen in tuberculosis. Tissue damage by complement activation can occur in rheumatoid arthritis.

The nurse suspects that a patient may be experiencing an acute bacterial infection based on which laboratory result? Increased platelet count Increased blood urea nitrogen Increased number of band neutrophils Increased number of segmented myelocytes

Increased number of band neutrophils When the demand for neutrophils increases to the extent that the bone marrow releases immature forms of neutrophils (bands) into circulation, this is called a shift to the left. It is common in patients with acute bacterial infections. The finding of an increased number of band neutrophils in circulation is called a shift to the left, which commonly is found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing, but they are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.

Which cells arrive first at the site of injury during the inflammatory response? Monocytes Neutrophils* Lymphocytes Macrophages

Inflammatory response is a sequential reaction to cell injury. Neutrophils are the first leukocytes to arrive at the injury site. They usually reach the site of injury within 6 to 12 hours. They engulf bacteria, other foreign material, and damaged cells. Monocytes are the second type of phagocytic cells that migrate from circulating blood. They usually arrive at the site within three to seven days after the onset of inflammation. Lymphocytes arrive later at the site of injury. Their primary role is related to humoral and cell-mediated immunity. On entering the tissue spaces, monocytes transform into macrophages. Together with the tissue macrophages, these macrophages assist in phagocytosis of the inflammatory debris.

component in the cell membrane is rapidly converted to produce prostaglandins?

Prostaglandins are produced from arachidonic acid. When cells are activated by injury, the arachidonic acid in the cell membrane is converted to produce prostaglandins. Cytokines, serotonin, and histamine do not have any role in prostaglandin production. They are mediators of inflammation.

A specimen that is taken from a patient's wound contains white blood cells, microorganisms, debris, and liquefied dead cells. The nurse recognizes that the findings indicate which type of inflammatory exudate? Purulent* Catarrhal Hemorrhagic Serosanguineous

Purulent exudate consists of white blood cells, microorganisms, debris, and liquefied dead cells. Purulent discharge is observed in furuncles, abscesses, and cellulitis. Catarrhal exudate contains mucus. Hemorrhagic exudate contains red blood cells. Serosanguineous exudate contains red blood cells and serous fluid.

The nurse assesses the fluid found in a patient's surgical drain. The nurse describes the inflammatory exudate as serosanguinous based on which characteristic? Presence of mucus Gelatinous ribbons Liquefied dead cells Semiclear pink appearance*

Serosanguineous inflammatory exudate is composed of red blood cells and will resemble semiclear pink exudate. Catarrhal exudate contains mucus. Fibrinous exudate looks like gelatinous ribbons. Purulent exudate contains liquefied dead cells.

A patient is hospitalized with a chronic heel ulcer. The nurse identifies which systemic manifestations of inflammation? Select all that apply. Select all that apply Temperature of 102.2°F (39.0°C) Heart rate 116 beats/min Elevated serum protein levels Nausea and anorexia White blood cell (WBC) count 8,000/μL with a shift to the right

Systemic manifestations of inflammation include an increased WBC count with a shift to the left (not the right), malaise, nausea and anorexia, increased pulse and respiratory rate, and fever. Normal vital sign ranges are as follows: temperature 97.6°F to 99.6°F (36.4°C to 37.6°C); respiratory rate 12 to 20 breaths/min; heart rate 60 to 100 beats/min. The normal WBC range is usually between 4,000 and 11,000 per microliter of blood. Elevated serum protein levels do not indicate inflammation.

Which systemic clinical manifestations does the nurse anticipate finding in a patient who has inflammation at an injury site? Select all that apply. Select all that apply Some correct answers were not selected Hematocrit 46% Body temperature of 101°F (38.3°C) Pulse rate of 120 beats/min White blood cell (WBC) count of 13,000/µL Respiratory rate of 10 breaths/min

The clinical manifestations of inflammation at the injury site are increased pulse and respiratory rate, increased white blood cell count and body temperature, and anorexia. Normal vital sign ranges are as follows: temperature 97.6°F to 99.6°F (36.4°C to 37.6°C); respiratory rate 12 to 20 breaths/min; heart rate 60 to 100 beats/min. The normal WBC range is usually between 4,000 and 11,000 per microliter of blood. A pulse rate of 120 beats/min is higher than normal. The WBC count of 13,000/µL is higher than normal. Inflammation results in increased metabolism and therefore increases the body temperature above normal. The hematocrit value of 46% is normal; the normal range for hematocrit is approximately 45% to 52% for men and 37% to 48% for women. The respiratory rate of 10 breaths/min is decreased; inflammation is manifested by increased respiratory rate.

incision three days after a surgical procedure and observes neatly approximated edges. Which phase of wound healing? Secondary intention Primary intention, granulation Primary intention, initial phase* Primary intention, maturation phase

The inflammatory phase is the initial phase of primary intention healing; this phase occurs three to five days after an injury. The wound edges are neatly approximated. Incision of edges and migration of epithelial cells are characteristics of the inflammatory phase. Secretion of collagen is a characteristic feature of the granulation phase. Remodeling of collagen is a characteristic feature of the maturation phase. Migration of fibroblasts is a characteristic feature of the granulation phase. Secondary intention involves wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss. These wounds may have edges that cannot be approximated.

The nurse caring for a patient with an ankle injury observes erythema and edema, along with serous fluid at the site of injury. Which stage of the inflammatory response is the patient exhibiting? Healing Cellular response Vascular response* Formation of exudate

The patient is exhibiting vascular response. The serous fluid is a result of the outpouring of fluid, seen in the early stages of inflammation. During cellular response, neutrophils and monocytes move from vascular circulation to the site of injury, and the site becomes purulent. The nature and quantity of exudate formation prior to healing depend on the severity of injury. When the wound heals, there are no signs of inflammation.

Which type of inflammatory exudate results from the rupture or necrosis of blood vessel walls? Serous Purulent Fibrinous Hemorrhagic*

The products of inflammation are known as inflammatory exudates. Exudates may ooze from the cuts or areas of inflammation. Hemorrhagic exudates result from rupture or necrosis of blood vessel walls during events such as hematoma, bleeding after surgery, or tissue trauma. Serous exudates result from an outpouring of fluid, seen in early stages of inflammation. Purulent exudates are associated with a preponderance of escaped leukocytes. Fibrinous exudates are formed by the action of fibrin ferment acting upon fibrinogen or fibrin-forming substances in the presence of calcium salts.

A patient with an inflammation reports malaise, nausea, and anorexia. The nurse identifies that the manifestations are indicative of which type of response? Local response Systemic response* Infectious response Acute inflammatory response

The systemic response to inflammation includes the manifestations of a shift to the left in the white blood cell (WBC) count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in two to three weeks and usually leaves no residual damage.

The nurse reviews white blood cell (WBC) count laboratory results from four patients. Which patient's data indicates a "shift to the left?"

To keep up with the demand for neutrophils, the bone marrow releases more neutrophils into circulation. This results in a high WBC count, especially the neutrophil count. Sometimes the demand for neutrophils increases to the extent that the bone marrow releases immature forms of neutrophils (bands) into circulation. This increased number of band neutrophils in circulation is called a shift to the left. It is common in patients with acute bacterial infections. Increased monocyte counts, decreased numbers of lymphocytes, and an absence of eosinophils are not referred to as a "shift to the left."

manifestations of inflammation Temperature of 100.8°F (38.2°C)* Respiratory rate of 30* Presence of erythema Heart rate 106 beats/min*

Vital signs are important to note with any inflammation, especially when an infectious process is present. With infection, the temperature may rise, and pulse and respiration rates may increase. Normal vital sign ranges are as follows: temperature 97.6°F to 99.6°F (36.4°C to 37.6°C); respiratory rate 12 to 20 breaths/min; heart rate 60-100 beats/min. Loss of function occurs due to pain and edema. Edema, erythema, and pain are local manifestations of inflammation.

when imflammation

Vital signs are important to note with any inflammation, especially when an infectious process is present. With infection, the temperature may rise, and pulse and respiration rates may increase. Normal vital sign ranges are as follows: temperature 97.6°F to 99.6°F (36.4°C to 37.6°C); respiratory rate 12 to 20 breaths/min; heart rate 60-100 beats/min. Loss of function occurs due to pain and edema. Edema, erythema, and pain are local manifestations of inflammation.

The nurse suspects that a patient may be experiencing an acute bacterial infection based on which laboratory result? Increased platelet count Increased blood urea nitrogen Increased number of band neutrophils* Increased number of segmented myelocytes

When the demand for neutrophils increases to the extent that the bone marrow releases immature forms of neutrophils (bands) into circulation, this is called a shift to the left. It is common in patients with acute bacterial infections. The finding of an increased number of band neutrophils in circulation is called a shift to the left, which commonly is found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing, but they are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.

The nurse develops a plan of care for a patient with a soft tissue injury to the arm. Which nursing intervention is included in the plan? Perform range of motion exercises on the arm to promote circulation. Elevate the arm above the level of the heart to reduce pain.* Avoid compression bandages to the arm to minimize impairment of the nerves. Apply heat to the arm for the first 24 hours to promote healing.

You Can Do It :)

Becaplermin

a recombinant human platelet-derived growth factor gel, actively stimulates wound healing. It is used to treat foot ulcers in patients with diabetes. Surgical debridement and collagenase are unnecessary without the presence of necrotic tissue. Since there is no eschar present, the use of autolytic debridement may destroy the healthy tissue.

Vitamin A

accelerates epithelialization by combining with the collagen shields of the skin. Vitamin D facilitates calcium absorption. B-complex vitamins act as coenzymes.

Aspirin

antiinflammatory drug that reduces capillary permeability

B-complex vitamins

as coenzymes

osteomyelitis

bone infection, rear but serious Corticosteroids are used to treat osteomyelitis. This drug suppresses immunity and masks classic manifestations of inflammation; thus a patient would present malaise. Salicylates are used to lower excessive body temperature and do not interfere with the immune mechanism. Potassium can strengthen the functions of the immune system. Vitamin D supplements facilitate calcium absorption.

compression bandage

brown elastic bandage

patient takes prednisone for rheumatoid arthritis

experience decreased white blood cell count Prednisone is a corticosteroid drug that interferes with the synthesis of lymphocytes, resulting in a decreased white blood cell count. Prednisone does not interfere with prothrombin time. Prednisone does not increase red blood cell count because it does not stimulate erythropoiesis. Serum protein levels are not affected by prednisone.

Vitamin D

facilitates calcium absorption.

purulent exudate

furuncles, abscesses, and cellulitis

febrile

having or showing the symptoms of a fever.

Vitamin C

helps in the synthesis of collagen and new capillaries.

Acetaminophen

helps maintain thermoregulation by acting on the heat-regulating center in the hypothalamus.

Catarrhal exudate

in mucus

Ibuprofen, piroxicam

nonsteroidal antiinflammatory drug that inhibits prostaglandin synthesis

signs of infection.

odor and purulent exudate

hemorrhagic exudate

red blood cells

Serosanguineous exudate

red blood cells and serous fluid

erythema

red skin

signs of inflammation

swelling redness loss of function pain Increases the permeability of the blood vessels by causing vasodilation, resulting in redness at the site. Inflammation causes a shifting of fluids to the interstitial spaces and fluid accumulation, resulting in swelling at the site. Swelling and pain can result in loss of cellular function at the inflammatory site.