chapter 11: inflammation and wound healing

vitals signs (fever) moderate fevers

-(up to 103F) usually produce few problems in most pts. if pts is very young or very old it is extremely uncomfortable -the use of antipyretics should be considered. -FEVER w immunosuppressed patient should be treated immediately w antibiotic therapy because infections can rapidly progress to septicemia. -FEVER greater than 104F can damage body cells and delirium and seizures can occur. -FEVER temperatures greater than 105.8F regulation by the hypothalamic temperature control center becomes impaired. Damage to the cells can occurs and to the brain.

infection can also be caused by ________

-heat, radiation, trauma, chemicals, allergens, and autoimmune reaction.

bands

-immature neutrophils released by the bone marrow into the circulation. (because of the demand)

systemic manifestations of inflammation

-increased WBC count w shift to left,malaise, nausea, and anorexia, increased pulse and resp rate and fever.

adequate nutrition

-is essential so that the body has necessary factors to promote healing when injury occurs. -high fluid intake is needed to replace fluid loss from perspiration.

Pus

-mixture of dead neutrophils, digested bacteria, and other cell debris accumulates as a creamy substance.

cellular response

-neutrophils and monocytes move from circulation to the site of injury.

histamine

-stored in granules of basophils, mast cells, platelets -causes vasodilation and increased capillary permeability

monocytes

-second type of phagocytic cells that migrate from circulating blood. -they usually arrive at the site within 3-7 days after the onset of inflammation. -monocytes transform into macrophages when entering tissue spaces.

what is osteomalacia?

Osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency.

A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1.Cloudy wound drainage 2.Absence of the gag reflex 3.Decreased urinary output 4.Restlessness with dyspnea

answer: Restlessness with dyspnea rationale:The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia. Cloudy drainage may indicate infection, which is not an immediate postoperative complication Decreased urinary output needs to be monitored but does not take priority.

popping, discontinuous sounds caused by air moving into previously deflated airways? what sound is this?

answer: Crackles

is a lower-pitched, coarse, continuous snoring sound that arises from the large airways? what sound is this?

answer: Rhonchus

After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis?

answer:redness of the eardrum Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination.

what bacteria causes food poisoning?

answer=Clostridium botulinum causes food poisoning

what is osteomylitis?

Osteomyelitis is infection of bone or bone marrow

what is pharyngitis?

Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis.

what is pneumonia??

Pneumonia is excess fluid in the lungs resulting from an inflammatory process.

Which benign condition shows silver scaly plaques on the skin?

Psoriasis

local manifestations of inflammation

Redness-hyperemia from vasodilation heat- (calor) increased metabolism at the inflammatory site pain- (dolor) changed in pH. nerve stimulation by chemicals (e.g histamine,prostaglandings) pressure from fluid exudate swelling-(tumor) fluid shift to interstitial spaces. fluid exudate accumulation. loss of function-swelling and pain.

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? A. Frequent examination of the character and quantity of exudate B. Monitoring for signs and symptoms of local or systemic infections C. Assessment of the patient's circulation distal to the location of the dressing D. Assessment of the range of motion of the ankle and the patient's activity tolerance

answer: C rationale=A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? Frequent examination of the character and quantity of exudate Monitoring for signs and symptoms of local or systemic infections Assessment of the patient's circulation distal to the location of the dressing Correct Assessment of the range of motion of the ankle and the patient's activity tolerance

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? A. Increased platelet count Incorrect B. Increased blood urea nitrogen C. Increased number of band neutrophils Correct D. Increased number of segmented myelocytes

answer: C rationale=The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but 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.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? A. Take the antibiotic until the wound feels better. B. Take the analgesic every day to promote adequate rest for healing. C.Be sure to wash hands after changing the dressing to avoid infection. Correct D. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. Correct E. Notify the health care provider of redness, swelling, and increased drainage.

answer: C and D rationale=Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing.

A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease?

answer: Esophageal pain may imitate the symptoms of a heart attack. rationale=Symptoms associated with myocardial infarction may be interpreted by a client as esophageal reflux and therefore ignored. - Laboratory workups help differentiate these two diagnoses. Tests, such as cardiac enzymes, can help to reveal a myocardial infarction, thereby facilitating differentiation between these problems.

Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells?

answer: Nevi Rationale=Nevi (moles) are hyperpigmented areas that vary in form and size. Nevi are a common benign condition of the skin that is associated with the grouping of normal cells derived from melanocyte-like precursor cells

what are steroids used for?

answer: are used for their antiinflammatory, vasoconstrictive, and antipruritic effects. -Steroids increase the incidence of infections because they are antiinflammatory agents and mask symptoms of infection. -Steroids increase fluid retention because they promote the reabsorption of sodium from the tubular fluid into the plasma. Although steroid ointments have an antipruritic effect, their major purpose after surgery is their systemic antiinflammatory effect.

A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client?

answer: nutritional needs rationale=To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished The consumption of a high-calorie, high-protein diet is advised.

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? A. Administer aspirin on a scheduled basis around the clock. B. Provide acetaminophen every 4 hours to maintain consistent blood levels. C. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F D. Provide drug interventions if complementary and alternative therapies have failed.

answer:B rationale= Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.

A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease?

answer= Involvement starting distally with rectal bleeding that spreads continuously up the colon rationale=Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pathology usually is in the descending colon in Crohn disease, it is primarily in the terminal ileum, cecum, and ascending colon. Ulcerative colitis, as the name implies, affects the colon, not the small intestine.

A nurse inspects a two-day-old intravenous (IV) site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?

answer= discontinue iv infusion rationale=The clinical findings indicate the presence of inflammation. The IV catheter should be removed to prevent the development of thrombophlebitis

A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing?

answer=Salicylate toxicity rationale=Excessive aspirin ingestion can influence the vestibulocochlear nerve (cranial nerve VIII), causing tinnitus and dizziness The client is experiencing symptoms of toxicity

A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide?

answer=To treat Helicobacter pylori infection rationale=Approximately two thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa and interfering with its protective function

A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client?

answer=hypovolemia rationale=Hypovolemia that results from a fluid shift from the intravascular compartment to the peritoneal cavity can cause circulatory collapse; this is a life-threatening event that requires immediate intervention

neutrophils

are the first leukocytes to arrive at the injury site (usually within 6-12 hrs. - they phagocytize (engulf) bacteria, other foreign material and damaged cells. -short life span of (24-48hrs) dead neutrophils accumulate.

macrophages

assist in phagocytosis of the inflammatory debris. -cleaning of the area before healing can begin. -have long life span. they can multiply and may stay in the damaged tissues for weeks.

vital signs (acute care) inflammation

-taking corticosteroids or receiving chemotherapy the manifestations of inflammation may be masked. -early symptoms of inflammation may be malaise or "just not feeling well" -with infection the temperature may rise, and pulse and resp rate may increase.

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? A. Adhesion B. Contractions C. Keloid formation D. Excess granulation tissue

Answer: D rationale=Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable.

A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress?

Answer:A bland, nonirritating diet is recommended during the acute symptomatic phase. -During the acute phase, a regular diet can cause discomfort. -Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea, and cola. - Bedtime snacks should be avoided because they may stimulate gastric acid secretion as well. -Gluten-free foods do not decrease gastric acid secretion. Low-carbohydrate foods do not decrease gastric acid secretion.

inflammatory response can be divided into______

vascular response,cellular response, formation of exudate, and healing

Which laboratory test will be elevated in a client with inflammatory arthritis?

answer=Erythrocyte sedimentation rate (ESR) rationale=The erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells fall through plasma. This rate is most significantly affected by an increased number of acute-phase reactants, which occur with inflammation. The ESR is chronically elevated with inflammatory arthritis

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? A. Serous B. Purulent C. Fibrinous D. Catarrhal

answer: B rationale= Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.

Elevated WBC

=to keep up with the demand of neutrophils, the bone marrow releases more neutrophils into circulation causing elevated WBC.. and especially neutrophils

Which immunomodulatory is beneficial for the treatment of clients with multiple sclerosis? 1.Interleukin 2 2.Interleukin 11 3.Beta interferon 4.Alpha interferon

answer: Beta interferon Beta interferon is an immunomodulator that is administered in the treatment of multiple sclerosis

While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record?

Answer: Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing

Hyperpigmented areas that vary in form and color ?

Nevi

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? A. Pain level B. Intake and output C. Oxygen saturation D. Level of consciousness

answer: B rationale= Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient.

what is thermography??

Thermography uses an infrared detector that measures the degree of heat radiating from the skin's surface. Therefore it is used to investigate the cause of an inflamed joint and in determining the client's response to antiinflammatory drug therapy.

Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to?

Urticaria

Utricaria

an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis.

which disease is caused by E coli?

answer= peritonitis Peritonitis is usually infectious and often life-threatening. It's caused by leakage or a hole in the intestines, such as from a burst appendix.

subacute inflammation

has the features of the acute process but lasts longer. -ex: infective endocarditis is a smoldering infection w acute features but lasts longer up to weeks or months

infection

involves invasion of tissues or cells by microorganisms such as bacteria,fungi, and viruses.

Atopic dermatitis

is a genetically influenced, chronic, relapsing disease associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.

Allergic contact dermatitis

is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens. Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens.

chemotaxis

is directional is the migration of WBCs to the site of injury, resulting in an accumulation of neutrophils and monocytes at the site.

inflammatory response

is sequential reaction to cell injury -it neutralized and dilutes the inflammatory agent, removes necrotic materials, and establishes an environment suitable for healing and repair.

chronic inflammation

lasts for weeks, months or even years. the injurious agent persists or repeatedly injures tissue. -predominant cell types are macrophages or lymphocytes. ex; rheumatoid arthritis and osteomyelitis. - the prolongation of inflammation may be the result of an autoimmune response and can lead to physical deterioration.

segmented neutrophils

mature neutrophils

shift to left

the finding of increased number of band neutrophils in circulation. -commonly found in pts w acute bacterial infections

acute inflammation

the healing that occurs in 2 to 3 weeks and usually leaves no residual drainage . -neutrophils are predominant cell type at the site