HESI Assessment

How do corticosteroid drugs delay wound healing?

Corticosteroid drugs impair phagocytosis by white blood cells, inhibit fibroblast proliferation and function, depress formation of granulation tissue, and inhibit wound contraction.

A patient is admitted to the medical unit with a 104.5° F temperature. Which nursing action would be most effective in restoring normal body temperature?

Give antipyretics on an around-the-clock schedule.

The nurse is discussing the beneficial aspects of fever with a group of senior citizens. Which beneficial aspects of fever would the nurse include in the discussion?

Increased proliferation of T cells Enhancement of interferon activity Increased killing of microorganisms

The nurse determines that a patient's abdominal surgical wound is healing by primary intention. Which phase best describes the migration of fibroblasts?

Granulation phase The migration of fibroblasts occurs in the , which lasts from five days to four weeks. In this phase, collagen is secreted and there is an abundance of capillary buds in the wound making it fragile.

What does protein do to help with healing?

Increasing the amount of protein in the diet will help to increase the synthesis of collagen, leukocytes, and fibroblasts, all of which are necessary for healing.

What do Neutrophils do in inflammation?

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.

A patient is prescribed acetaminophen 650 mg per rectum every six hours as needed for fever greater than 102° F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication?

Intake and output - Acetominophen can effect kidney function

Vitamin D helps with what in wound repair?

Vitamin D facilitates calcium absorption.

The nurse is assessing the effectiveness of the administration of cefazolin for treatment of a bacterial infection. What outcome does the nurse determine demonstrates effectiveness of the medication regimen?

WBC count 8500/μL, temperature 98.4° F A WBC count of 8500/μL and a temperature of 98.4° F are within the normal range.

The nurse is educating a patient with a wound that has been difficult to heal and who is scheduled for hyperbaric oxygen therapy. The patient asks, "How will this help when everything else hasn't?" What is the best response by the nurse?

"It kills anaerobic bacteria." "It increases the effectiveness of certain antibiotics." "It increases the killing power of white blood cells (WBCs)." The therapy also promotes angiogenesis (growth of new blood vessels) to facilitate wound healing. Hyperbaric oxygen therapy accelerates formation of granulation tissue, which in turn accelerates the wound healing process.

The nurse is preparing a patient for discharge after an appendectomy. The patient asks why they are unable to lift anything heavy for 6 weeks. What is the best response by the nurse?

"The wound is in the maturation phase of healing during this period." The maturation phase begins with scar contraction. It begins after seven days and may continue for several months or years. The fibroblasts disappear during this period, and the wound becomes stronger. Lifting heavy weights may tear the wound apart because of the pressure exerted.

While reviewing a patient's laboratory reports, the nurse finds Mycobacterium strains in the patient's sputum. Which physiologic change does the nurse expect in this patient?

Granuloma formation 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.

A patient sustained multiple lacerations and wounds in a motor vehicle crash. Which food items should be encouraged to promote healing in the patient?

Guava Strawberry Kiwi fruits Vitamin C is a very important nutrient that helps in wound healing. Deficiency of vitamin C delays formation of collagen fibers and capillary development. The nurse should encourage the patient to eat guava, strawberries, and kiwi, because these fruits are rich in vitamin C. Apples and bananas are not rich sources of vitamin C.

The nurse has an order for mechanical debridement of a patient's pressure ulcer. Which activity will the nurse plan?

Application of wet-to-dry dressings Two methods are used for mechanical debridement: wet-to-dry dressings and wound irrigation.

A nurse is assessing the risks of patients for developing pressure ulcers. Which patients are at the highest risk for developing pressure ulcers?

A 65-year-old female patient with quadriplegia; nonambulatory A 49-year-old male patient with sepsis; responds in grunts; disoriented A 58-year-old female patient with stroke and incontinence of urine and stool; ambulates with a wheelchair Pressure develops in patients who are nonambulatory and who do not change their positions often. Patients who have quadriplegia, are disoriented, are nonambulatory, or have had a brain injury are at high risk of developing pressure ulcers. These patients cannot move by themselves and need help to change position. Therefore they are at high risk of developing pressure ulcers.

What is the range of a normal WBC count?

A normal WBC is 4000 to 11,000/μL.

The nurse is reviewing the medical reports of four patients. Which patient may show a blunted febrile response to infection?

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. NSAIDS - may mask early signs of infection

The nurse is assessing four patients. Which patient may show catarrhal inflammatory exudate?

A patient with runny nose due to laryngitis. Catarrhal exudate is seen in a patient with a runny nose due to an upper respiratory tract infection (for example, laryngitis).

A nursing student is learning about prostaglandins and their role in vasodilation. What is the source of prostaglandins?

Arachidonic acid Prostaglandins are produced from arachidonic acid. When cells are activated by injury, the arachidonic acid in the cell membrane is converted to produce prostaglandins.

A nurse is caring for an older adult asthmatic patient who underwent a hernia repair six hours previously. The temperature of the patient is 103.2 oF, the pulse rate is 99/min, and the blood pressure is 100/70 mm Hg. What would be the most effective nursing intervention?

Administer antipyretic drugs routinely. Because the patient is an older adult and has pulmonary disease, use of antipyretic drugs should be considered to lower the temperature to a particular set point. Many older adult patients are unable to tolerate higher core temperatures because of compromised immunity.

The nurse is completing discharge teaching for a patient being released from the emergency department after evaluation of an ankle sprain. The nurse is teaching the patient about the rest, ice, compression, and elevation (RICE) approach to dealing with soft tissue injuries. Using RICE, when should the nurse instruct the patient to use heat?

After 24 to 48 hours Heat should be used after 24 to 48 hours (after cold application) to increase circulation to the inflamed site. Cold is used immediately to promote vasoconstriction and decrease swelling, pain, and congestion at the site.

The nurse is preparing to perform a dressing change for a wound that is irregularly shaped and draining. What type of dressing should the nurse apply that forms a nonsticky gel?

Alginate Alginates form a nonsticky gel on contact with a draining wound. They are easy to use over irregularly shaped wounds and generally require a secondary dressing.

The nurse is reviewing prescribed treatments for a patient with a debrided stage III sacral pressure ulcer. Which one of the prescriptions should a nurse question as part of the plan of care for a patient with this ulcer?

Clean the ulcer every shift with povodone-iodine (Betadine) solution.

The nurse is preparing to administer a medication that has the action to reduce capillary permeability. What medication will the nurse administer to the patient?

Aspirin

A patient in an ambulatory care setting has been prescribed a semirigid brace to support a wrist injury. What action will the nurse take to ensure optimal comfort for the patient?

Assess distal pulses and capillary refill. The nurse should assess distal pulses and capillary refill before and after application of a semirigid brace or compression device to evaluate whether compression has compromised the patient's circulation.

B-complex vitamins helps with what in wound repair?

B-complex vitamins act as coenzymes.

occurs due to an increase in metabolism at the inflammatory site.?

Calor(heat)

An older adult patient is transferred from the nursing home with a black wound on the heel. What priority treatment should the nurse prepare the patient for?

Debride the nonviable, eschar tissue to allow healing.

What does the nurse expect to find in the laboratory report of a patient taking prednisone for rheumatoid arthritis?

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.

The nurse is educating a patient and family members about pressure ulcers. Which is the priority nursing action when conducting this educational session?

Demonstrate correct positioning to prevent skin breakdown Patient and caregiver education regarding pressure ulcers begins with prevention; therefore the nurse's first priority is to teach the patient and family the correct positioning for preventing the occurrence of skin breakdown. Next, the nurse should assess the patient and family's skill levels in conducting wound care, along with their financial resources to do so. The nurse should then teach the patient and family to inspect the skin each day. Finally, the nurse should educate the patient and family about the importance of proper nutrition as it pertains to wound healing.

How does diabetes delay wound healing?

Diabetes mellitus decreases collagen synthesis, retards early capillary growth, impairs phagocytosis, and reduces the supply of oxygen and nutrients secondary to vascular disease.

The nurse is assessing a patient prior to applying a compression bandage. What are priority assessments the nurse must make before applying the bandage?

Distal pulses Capillary refill 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 Fluid and Electrolytes should be checked after applying negative-pressure wound therapy because fluid and electrolyte loss may occur.

occurs due to a change in pH and pressure from fluid exudate.

Dolor (pain)

What happens during Cellular response in wound healing?

During cellular response, neutrophils and monocytes move from vascular circulation to the site of injury, and the site becomes purulent.

What is Evisceration ?

Evisceration is a complication of wound healing that occurs when wound edges separate to the extent that intestines protrude through the wound.

The patient previously had a breast reduction. She has come to the surgeon's office complaining about excess soft pink tissue where a scar should be forming. What complication of wound healing does the nurse recognize this to be?

Excess granulation tissue, the excess soft pink tissue on the wound, is this complication of wound healing. 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.

The nurse assesses that there is fecal material drainage coming from an abscess in the perianal area. Which complication of wound healing does the nurse suspect has occurred?

Fistula formation Fistula is a complication of wound healing in which an abnormal passage is formed between organs or a hollow organ and skin.

A patient has moderate to heavy exudate from his wound. What are the types of wound dressings that the nurse should use for this patient?

Foam dressing Alginate dressing Hydrocolloidal dressing

A patient is on bed rest for several weeks. What areas should the nurse assess in order to intervene early to prevent complications from pressure? .

Heel Sacrum Scapular region A pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. The heel and sacrum are the most common sites of pressure ulcers. Pressure ulcers also develop on the skin over the scapula bones.

Hydrogels dressings:

Hydrogels donate moisture to a dry wound and maintain a moist environment that rehydrates wound tissue.

A nurse is caring for a patient who has developed gangrenous ulcers on the foot, making walking difficult. There is purulent drainage from the ulcer, and black adherent necrotic tissue can be observed. What should be included in the plan of care for the patient?

Hydrotherapy Topical debridement Absorptive dressing covered with gauze Transparent film dressings are used in dry and uninfected wounds or wounds with less drainage. Because this wound is infected and has purulent discharge, transparent film dressing cannot be used. Gentle atraumatic cleansing is required in freshly inflicted red wounds. Gentle cleansing will not remove the necrotic tissue present in this case.

What is Hypertrophic scars ?

Hypertrophic scars are inappropriately large, red, raised, and hard scars that occur due to overabundance of collagen during healing.

What do these drugs do in wound healing? Ibuprofen Piroxicam Acetaminophen

Ibuprofen is a nonsteroidal antiinflammatory drug that inhibits prostaglandin synthesis. Piroxicam is a nonsteroidal antiinflammatory drug that inhibits the synthesis of prostaglandin. Acetaminophen helps maintain thermoregulation by acting on the heat-regulating center in the hypothalamus.

The nurse is orienting a new nurse in the long-term care facility to the policy of prevention of complications related to the older adult and pressure ulcers. What should the nurse include regarding the assessment of pressure ulcers?

In home care, reassess patients at every visit. In acute care, reassess patients for pressure ulcers every 24 hours. In long-term care, reassess the patient weekly for the first 4 weeks after admission. In acute care, patients should be reassessed for pressure ulcers every 24 hours because the patients are at high risk due to their disease condition and lack of mobility. In long-term care, reassess residents weekly for the first four weeks after admission and then at least monthly or quarterly. The patient may be mobile and able to take care of himself or herself; therefore, a weekly assessment is sufficient. In home care, reassess patients at every nurse visit because the patient may not be able to locate pain on the skin area caused by pressure ulcers.

A patient sustained severe injuries following a motor vehicle accident and is recovering. What nutritional instructions should the nurse give to the patient?

Include foods rich in vitamin C. Include foods rich in vitamin B 12. Consume adequate quantities of water.

How does fat help with wound healing?

Including a moderate amount of fats will help healing because the fats help in the synthesis of fatty acids, which are part of the cell membrane.

A patient is being discharged from the health care facility after an abdominal cholecystectomy. What should the nurse teach the patient and the family about wound care?

Increase fluid intake. Consume a high-protein diet. Observe the wound for complications. Follow aseptic procedures during dressing change.

A nurse is caring for a patient who is undernourished and sustained a trauma to the chest. How should the nurse plan the diet of the patient to ensure proper nutrition for adequate wound healing?

Increase the protein intake to promote synthesis of collagen. Increase the intake of vitamin A because it helps in epithelialization. Include a moderate amount of fats to help in synthesis of fatty acids.

The nurse determines that the patient may be experiencing an acute bacterial infection. What laboratory result would confirm this suspicion?

Increased number of band neutrophils 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.

Which physiologic change is associated with fever during inflammatory conditions?

Increased proliferation of T cells Fever is mediated by a host macrophage product called endogenous pyrogen (EP) that stimulates the proliferation of T cells. Fever increases the action of neutrophils and promotes phagocytosis. Vasodilators increase blood flow rate. Fever increases destruction of microorganisms by enhancing the activity of interferon.

A patient has a deep, red wound caused by trauma while playing football. What interventions should the nurse provide while dressing this moderate red wound?

Keep the wound moist. Use transparent film to dress the wound. Use an adhesive semipermeable dressing to cover this wound. Keeping the wound moist is extremely important in a red wound. A moist environment helps in granulation and re-epithelialization. Transparent films and adhesive semipermeable dressings are permeable to oxygen and are used in red wounds. Wound irrigations are usually avoided because unnecessary manipulation can destroy the granulation tissue.

What is Keloid formation ?

Keloid extends beyond the edges of the wound and may form tumor-like masses of scar tissue.

The nurse is reviewing the laboratory report of a patient who has been admitted to the hospital for a stab wound in the abdomen. Which finding is likely to be seen in the report?

Leukocytosis - Leukocytosis results from an increase in the release of WBCs as a result of inflammation as a response to the stab wound. Albuminuria is the presence of albumin in urine. Polycythemia is an increase in the RBC count. Thrombocytopenia is a relative decrease of platelets in the blood.

What do Lymphocytes do in inflammation?

Lymphocytes arrive later at the site of injury. Their primary role is related to humoral and cell-mediated immunity.

What do Monocytes do in inflammation?

Monocytes are the second type of phagocytic cells that migrate from circulating blood. They usually arrive at the site within 3 to 7 days after the onset of inflammation. On entering the tissue spaces, monocytes transform into macrophages. Together with the tissue macrophages, these macrophages assist in phagocytosis of the inflammatory debris.

The nurse is caring for a patient who has a healing abdominal wound. What factors does the nurse determine that could possibly cause a wound dehiscence?

Obesity Infection Seroma formation Obesity, presence of infection, and seroma formation between the margins of the wound may increase the risk of wound dehiscence. People who are obese are at high risk for dehiscence because adipose tissue has less blood supply and may slow healing. Infection causes an inflammatory process. The granulation tissue formed may not be strong enough to withstand forces imposed on the wound. A pocket of fluid, seroma, formed between tissue layers, prevents the edges of the wound from coming together.

How does obesity delay wound healing?

Obesity decreases blood supply to the wound, causing delayed wound healing.

A nurse has assessed and planned care for patients in a unit. Which patient care tasks could be delegated to the unlicensed assistive personnel (UAP)? .

Perform dressing changes for chronic wounds using clean technique. Report changes in wound appearance or drainage to the registered nurse. Empty wound drainage containers and document drainage amount on the intake and output record.

A nurse is caring for a patient who is receiving negative-pressure wound therapy. Which parameters should be monitored for a patient on negative-pressure wound therapy?

Platelet count Prothrombin time Partial prothrombin time Negative-pressure wound treatment creates negative pressure in the wound bed and pulls excess fluid from the wound, reduces bacterial load, and encourages blood flow to the wound bed.

Which cells release growth factors that initiate the healing process?

Platelets release growth factors that initiate the healing process. Monocytes help clean the area before healing. Neutrophils play an important role in producing inflammatory response.

The nurse is assessing a pressure ulcer on a newly admitted patient and needs to record images of the wound at the various stages of healing using digital photography to monitor progress. What precautions should the nurse take when obtaining images of the wound?

Position the patient the same way for each image. If the patient is positioned in the same way for each image, the angle in which the photo is taken will not change; this will help record the wound progression correctly.

The nurse is reviewing the laboratory data from four patients. Which patient's data from a white blood cell count with differential indicates a "shift to the left?"

Presence of band neutrophils Immature forms of neutrophils called band neutrophils will be present early in the response to infection. This is referred to as a "shift to the left" and can be an early sign of the white blood cell response

The nurse is assessing a surgical wound 3 days after the procedure and observes neatly approximated edges. What phase of wound healing does the nurse determine the patient is experiencing?

Primary intention, initial phase

Which action by the nurse would be most helpful in treating a patient who is experiencing chills related to an infection?

Provide a light blanket Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient. Encouraging a hot shower, monitoring temperature every hour, and turning up the thermostat in the patient's room are not the most helpful actions in treating a patient with chills.

Which type of exudate does the nurse likely observe in a patient who has diffuse inflammation of the connective tissue?

Purulent Diffuse inflammation in connective tissue is called cellulitis; this condition produces purulent exudate.

The primary health care provider instructs the nurse to elevate a patient's injured extremity. What should the nurse check for in the patient's reports before elevating the patient's extremity?

Reduced arterial circulation Elevation of an extremity above the level of the heart increases venous and lymphatic return. To reduce the risk of compromised perfusion, the nurse should check the patient's reports for reduced arterial circulation before elevating the injured extremity.

occurs due to hyperemia from vasodilation.

Rubor

A patient has serosanguineous inflammatory exudate. What characteristic of this exudate should the nurse document?

Semiclear pink exudate Serosanguineous inflammatory exudate is composed of red blood cells and will resemble semiclear pink exudate. Serous exudate is seen in a patient with pleural effusion; this exudate occurs due to an outpouring of fluid.

Semipermeable transparent film dressings:

Semipermeable transparent films allow visualization of the wound and are minimally absorbent.

Which term refers to the directional migration of white blood cells to the site of a cellular injury?

Shift to the left

The patient is admitted with a pressure ulcer with full-thickness skin loss involving damage to subcutaneous tissue. How should the nurse document it?

Stage III Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage I ulcers have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage II ulcers are partial-thickness with a red-pink wound bed. Stage IV ulcers involve extensive destruction of tissue with exposed bone, tendon, or muscle.

A nurse is examining the pressure ulcer of a patient and observes that subcutaneous fat is visible in the ulcer, but bones, muscle, and tendon are not visible. Slough is present, and there is tunneling of the ulcer. From this observation, what stage of the ulcer should the nurse record in the patient's medical record?

Stage III There are four stages of pressure ulcers. In stage III, subcutaneous fat is visible in the ulcer, but bones, muscle, and tendon are not visible. The slough is present, and there is tunneling of the ulcer.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching?

Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. Notify the health care provider of redness, swelling, and increased drainage. 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 is needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. B-complex vitamins facilitate metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection.

A nurse is preparing for the discharge of a patient with a pressure ulcer and includes the caregiver in the education. What should the nurse include in the home care instructions?

Teach the caregiver the "no touch" technique for changing the dressing.

The nurse is caring for an older adult who has a compound fracture of the radius. The nurse observes manifestations of inflammation. Which symptoms should the nurse document as signs of infection in this older patient? .

Temperature 100.8°F Respiratory rate of 30 Heart rate 106 beats/min

A patient is admitted with a chronic heel ulcer. What assessment findings would indicate systemic manifestations of inflammation?

Temperature 102.2°F Heart rate 116 beats/min Patient reports nausea and anorexia 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.

Describe the initial phase of healing

The initial phase lasts from three to five days. In this phase, the migration of epithelial cells takes place. The clot serves as a meshwork for starting capillary growth.

Describe the maturation phase of healing

The maturation phase lasts from seven days to several months. In this phase, remodeling of collagen and strengthening of the scar occurs.

A patient is one day postoperative after having a hernia repair. During the morning assessment, the nurse notes that the patient has incisional pain, a 99.2° F temperature, slight redness at the incision margins, and 20 mL of serosanguineous drainage in the Jackson-Pratt drain. Based on these assessment data, what conclusion would the nurse make?

The patient is experiencing a normal inflammatory response. The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function

A patient with a major wound is admitted to the hospital. When assessing this patient, what does the nurse identify as factors that may result in delayed healing of the wound?

The patient is obese. The patient suffers from diabetes mellitus. The patient was on corticosteroid medications for a long time. Hypertension and hyperlipidemia do not have direct effects on wound healing.

What should the patient consume in diet to promote wound healing and what supplement helps with this?

The patient should consume a diet high in protein, carbohydrate, and vitamins with moderate fat to promote healing. The patient should take vitamin B supplements to prevent deficiency, which could disrupt metabolism of protein, fat, and carbohydrate.

The nurse is preparing to apply heat at the site of inflammation to a patient who sustained an injury to the arm. What is the best explanation to the patient as to the reason for this therapy?

To localize the inflammatory agents Heat application is used to localize the inflammatory agents and promote healing by increasing the circulation to the inflamed site and subsequent removal of debris.

A patient has fever associated with inflammation at an injury site. The nurse administers acetaminophen to the patient around the clock. What is the rationale behind this nursing intervention?

To prevent acute swings in temperature

What manifestation is observed in a patient due to fluid shift to interstitial spaces in an inflammatory condition?

Tumor Inflammation causes a fluid shift to interstitial spaces and an accumulation of fluid exudate. This results in tumor.

A bedridden patient has pressure ulcers. What are the priority interventions that a nurse should take while cleaning these ulcers?

Use noncytotoxic solution to clean the wound. After cleaning the wound, cover it with gauze dressing. Irrigate the wound using a 30-mL syringe and 19-gauge needles.

A nurse is responsible for the wound management of a bedridden patient with pressure ulcers. Which actions will help promote wound healing?

Using a 30-mL syringe and a 19-gauge needle for irrigating the wound Keeping the pressure ulcer slightly moist to help proliferate epithelialization Removing the necrotic tissue on the pressure ulcer using autolytic debridement Using an irrigation pressure of 4 to 15 psi to adequately clean the pressure ulcer

A nurse caring for a patient with an ankle injury observes erythema and edema along with serous fluid at the site of injury. What stage of the inflammatory response is the patient exhibiting?

Vascular response The patient is exhibiting vascular response. The serous fluid is a result of the outpouring of fluid, seen in the early stages of inflammation.

The nurse assesses a patient with an infiltrated intravenous (IV) site and observes rubor around the insertion site. What does the nurse determine has occurred related to the infiltration?

Vasodilation Inflammation causes a release of inflammatory mediators, which results in vasodilation, hyperemia, and increased capillary permeability. Vasodilation causes redness, or rubor, at the inflammatory site.

The nurse is administering a vitamin supplement to a patient with a surgical wound. What supplement will the nurse administer to the patient that will accelerate epithelialization?

Vitamin A Vitamin A accelerates epithelialization by combining with the collagen shields of the skin.

Vitamin C helps with what in wound repair?

Vitamin C helps in the synthesis of collagen and new capillaries. helps in epithelialization, so its intake should be increased.

A nurse is providing care to a patient who is scheduled for mechanical debridement. What treatments will the nurse assist the patient with? .

Whirlpool Wound irrigation Wet-to-dry dressings There are four types of debridement: surgical, mechanical, autolytic, and enzymatic. Mechanical debridement has three methods: wet-to-dry dressings, wound irrigation, and whirlpool. Whirlpool is used when minimal debris is present. Wound irrigation involves debriding the wound with high irrigation pressure. Wet-to-dry dressings involve application of open-mesh gauze moistened with normal saline. It is packed on or into a wound surface and allowed to dry.

Foams dressings:

are sheets that hold large amounts of exudates and mostly require gauze wrapping.

Purulent exudate:

contains liquefied dead cells.

Catarrhal exudate:

contains mucus. Catarrhal exudate is seen in a patient with a runny nose due to an upper respiratory tract infection (for example, laryngitis).

Fibrinous exudate:

looks like gelatinous ribbons. 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. Fibrinous exudate is seen in surgical drain tubing.

Define: Chemotaxis

refers to the directional migration of white blood cells to an injury site. Cell lysis refers to cell rupture, leading to cell death. Chemical mediation describes the mediation of the inflammatory response by a variety of chemical mediators. A shift to the left refers to the presence of band neutrophils, which are an early sign of inflammation.

What are the four types of debridement?

surgical: Surgical removal of eschar is referred to as surgical debridement. mechanical: wet-to-dry dressings and wound irrigation. autolytic: Semiocclusive and occlusive dressings are a method of autolytic debridement. enzymatic: The use of topical drugs to dissolve necrotic tissue is referred to as enzymatic debridement. Pg 170