Inflammation and wound healing

3 beneficial aspects of fever

- increased killing of microbes -increased phagocytosis -increased proliferation of t-lymphocytes

Acute inflammatory response

-healing occurs in 2-3 weeks usually leaving no residual damage -neutrophils are the predominant cell type

Systemic response to inflammation (5)

-increased white blood cell count (WBC) with "shift to left" -malaise or fatigue -nausea and anorexia -increased pulse and respiratory rate -fever

Chronic inflammatory repsonse

-may last years -agent that is causing damage persists or repeatedly injures or re-injures site -lymphocytes and macrophages

Local response to inflammation (5)

-redness -heat -pain -swelling -loss of function

Subacute inflammatory response

-same feature as acute but lasts longer than 2-3 weeks

What do cytokines cause?

cause fever by initiating metabolic changes in temperature-regulating center in hypothalamus

onset of fever is triggered by what?

cytokines

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 Purulent 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.

during a fever what would the patient experience?

The patient will experience chills and shivering and seek warmth, but the body is hot and needs to reach the core body temp

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Assess the ankles range of motion (ROM). d. Assess whether the patient can bear weight on the affected ankle.

A. elevate the ankle above heart level Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues.

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient takes insulin daily. b. The patient states that the ulcers are very painful. c. The patient has had the heel ulcers for the last 6 months. d. The patient has several old incisions that have formed keloids.

A. the patient takes insulin daily Chronic insulin use indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patients pain will be implemented, but pain does not directly affect wound healing.

A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. b. Start antibiotic therapy. c. Redress the wound with wet-to-dry dressings. d. Continue to monitor the wound for purulent drainage.

ANS: A The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well

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 B) Increased blood urea nitrogen C) Increased number of band neutrophils D) Increased number of segmented myelocytes

Answer: C increased number of band neutrophils 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.

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient states that the ulcers are very painful. b. The patient has had the heel ulcers for the last 6 months. c. The patient has several old incisions that have formed keloids. d. The patient takes corticosteroids daily for rheumatoid arthritis.

D. the patient that takes corticosteroids daily for rheumatoid arthritis

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

c. stage III A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound

A. low serum albumin level With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing.

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurses highest priority? a. Maintaining the patients blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102 F (38.9 C.) D. Redressing the surgical incision with a dry, sterile dressing twice daily

A. maintaining the patients blood glucose within a normal range Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition also is important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102 F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing.

A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/L and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. b. Start antibiotic therapy. c. Redress the wound with wet-to-dry dressings. d. Continue to monitor the wound for purulent drainage.

A. obtain wound cultures The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? A) A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F B) An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F C) A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F D) A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F

Answer: A Moderate fevers (up to 103°F) usually produce few problems in most patients and do not require antipyretic therapy. If the patient is very young or very old, is extremely uncomfortable, or has a significant medical problem (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. High fevers (above 104°F) should be treated with antipyretics. High fevers can damage body cells and cause delirium and seizures.

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 Any compression dressing requires vigilant assessment of the circulation distal to the dressing site because tissue and nerve damage is a significant risk. This supersedes the importance of assessing the patient's mobility. Exudate and infection would not normally accompany a soft tissue injury such as a sprain.

An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? A) Dress it with an absorbent dressing for exudate. B) Handle the wound gently and let it dry out to heal. C) Debride the nonviable, eschar tissue to allow healing. D) Use negative-pressure wound (vacuum) therapy to facilitate healing.

Answer: C With a black wound, the immediate therapy should be debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first. The red wound is handled gently because it is granulating and re-epithelializing, but it must be kept slightly moist to heal. The negative-pressure wound (vacuum) therapy is used to remove drainage and is more likely to be used after debridement.

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles b. The newly admitted patient with a stage IV pressure ulcer on the coccyx c. The patient who has been receiving chemotherapy and has a temperature of 102 F d. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change

C. the patient who has been receiving chemotherapy and has a temperature of 102 F Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient.

The nurse will perform which action when doing a wet-to-dry dressing change on a patients stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

D. administer the ordered PRN hydrocodone (lortab) 30 minutes before the dressing change Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.

A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound? a. Red wound b. Yellow wound c. Full-thickness wound d. Stage III pressure ulcer

a. red wound The description is consistent with a red wound. A stage III pressure ulcer would expose subcutaneous fat. A yellow wound would have creamy colored exudate. A full-thickness wound involves subcutaneous tissue, which is not indicated in the wound description.

A patients 4 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)

c. hydrocolloid dressing The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

c. rising body temperature The patients complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature.

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? A) The wound will be stapled together until it heals. B) The healing will contract the area to close the wound. C) The wound will be left open and heal from the edges inward. D) The wound will be sutured after the current infection is controlled.

Answer: C With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled.

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. D) Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. E) Notify the health care provider of redness, swelling, and increased drainage.

Answer: C, D 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.

The nurse assesses a patients surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a.Obtain wound cultures. b.Document the assessment. c.Notify the health care provider. d.Assess the wound every 2 hours.

B. document the assessment The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.

D. ask about fatigue or feelings of malaise Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be just not feeling well.

10. A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother? a. Change the patients bedding frequently. b. Use a hydrocolloid dressing over the ulcer. c. Record the size and appearance of the ulcer weekly. d. Change the patients position at least every 2 hours.

D. change the patients position at least every 2 hours The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching, but the most important instruction is to change the patients position at least every 2 hours.

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose 136 mg/dL b. Oral temperature 101 F (38.3 C) c. Patient complaint of increased incisional pain d. Separation of the proximal wound edges by 1 cm

D. separation of the proximal wound edges by 1 cm Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly.

After the home health nurse teaches a patients family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member places contaminated dressings in a plastic grocery bag. d. The family member dries the wound using a hair dryer set on a low setting.

D. the family member dries the wound using a hair dryer on a low setting Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care.

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe.d. d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

D. the new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate.

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who has increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

D. the patient who requires a hydrocolloid dressing change for a stage III sacral ulcer LPN/LVN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN).

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas

d. a patient who has a wound with purulent drainage and dry brown areas Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patients oral temperature again in 4 hours.

d. check the patients oral temperature again in 4 hours Mild to moderate temperature elevations (less than 103 F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patients health care provider or to use a cooling blanket for a moderate temperature elevation.