🟧 Chapter 11 Inflammation and Healing

7. An 85-yr-old patient has a score of 16 on the Braden Scale. What should the nurse include in the plan of care? a. Implementing a 1-hour turning schedule with skin assessment. b. Elevating the head of bed to 90 degrees when the patient is supine. c. Continuing with weekly skin assessments with no special precautions. d. Placing a silicone foam dressing on the patient's sacrum to prevent breakdown

A Rationale: A patient with a total Braden score of 16 or less is at risk for pressure injuries. Pressure injuries can be prevented by several strategies: Using an established risk assessment tool; repositioning frequently (every 1 hour); using devices to redistribute pressure (e.g., overlay mattresses, wheelchair cushions); removing excessive moisture on the skin; avoiding massage over bony prominences; positioning with pillows; and assisting the patient in maintaining a healthy weight

1. A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight erythema at the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The patient has a normal inflammatory response. b. The abdominal incision shows signs of an infection. c. The abdominal incision shows signs of impending dehiscence. d. The patient's health care provider must be notified about her condition.

A Rationale: The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss of function. Systemic manifestations of inflammation include an increased white blood cell (WBC) count with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.

8. Which patients are at most risk for pressure injuries? Select all that apply. a. A patient with right sided-paralysis and fecal incontinence b. An older adult who is alert and needs assistance to ambulate c. A young adult patient with paraplegia after a gunshot wound d. A morbidly obese patient who has an open abdominal wound e. An ambulatory patient who has occasional stress incontinence f. A young adult with a tibial fracture from a motor vehicle accident

A,C,D Rationale: Patients at risk for pressure injuries include those who are older, have had spinal cord injuries or trauma, have diabetes, are incontinent, or are immobile.

5. Which patient has the greatest risk for experiencing delayed wound healing? a. A 65-yr-old woman with stress incontinence b. A 52-yr-old obese woman with type 2 diabetes c. A 78-yr-old man who has a history of hypertension d. A 30-yr-old man who drinks 2 alcoholic beverages per day

B Rationale: Two primary factors that can interfere with wound healing include obesity and diabetes mellitus, which are both present. Other factors include smoking, drugs (e.g., corticosteroids, chemotherapy), advancing age, poor health, anemia, and infection.

2. The nurse assessing a patient with a chronic leg wound finds local signs of erythema, and the patient reports pain at the wound site. What would the nurse expect to be ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound

B. Rationale: Neutrophils and monocytes move from the circulation to the site of injury. The bone marrow releases more neutrophils into circulation, which results in elevation of the WBC count, especially the neutrophil count. If the bone marrow releases immature forms of neutrophils (i.e., bands) into circulation, a shift to the left occurs. Patients with acute bacterial infections have high WBC counts with a shift to the left.

3. A patient in the unit has a 103.7°F temperature. Which intervention would be most effective in restoring normal body temperature? a. Using a cooling blanket while the patient is febrile b. Giving antipyretics on an around-the-clock schedule c. Providing increased fluids and have the UAP give sponge baths d. Giving prescribed antibiotics and placing warm blankets for comfort

B. \Rationale: 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 an 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 giving the agents regularly and at 2- to 4-hour intervals. 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.

4. A nurse is caring for a patient who has a pressure injury that is treated with debridement, irrigations, and moist gauze dressings. How would the nurse expect healing to occur? a. Cell regeneration b. Tertiary intention c. Secondary intention d. Remodeling of tissues

C Rationale: A pressure injury can provoke an inflammatory reaction that results in large amounts of exudate and wide, irregular wound margins with extensive tissue loss. Pressure injuries may have edges that cannot be approximated. This type of wound heals by secondary intention. The healing and granulation take place from the edges inward and from the bottom of the wound upward until the defect is filled. Granulation tissue develops, and a large scar results.

6. Which order should a nurse question in the plan of care for an older adult, immobile stroke patient with a pink, clean stage 3 pressure injury? a. Pack the wound with foam dressing. b. Turn and position the patient every hour. c. Clean the wound every shift with Dakin's solution. d. Assess for pain and medicate before dressing change.

C Rationale: Topical antimicrobial and antibacterial agents (e.g., povidone-iodine [Betadine], sodium hypochlorite [Dakin's solution], hydrogen peroxide [H2O2], chlorhexidine [Hibiclens]) should be used with caution in wound care because they can damage the new epithelium of healing tissue and delay healing. These topical agents should never be used in a clean, granulating wound.

9. An 82year-old man is being cared for at home by his family. A pressure injury on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

C. Rationale: Characteristics of a stage 3 injury include full-thickness tissue loss; visibility of subcutaneous fat but not of bone, tendon, and muscle; and slough that may be present but does not obscure the depth of tissue loss and that may include undermining and tunneling.

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

Correct Answer: A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F Rationale: 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.

Which patient is most at risk for the development of a pressure injury? An older patient who is septic, bedridden, and incontinent An obese woman with leukemia who is receiving chemotherapy A middle-aged thin man in a halo cast after a motor vehicle accident An older adult with type 1 diabetes admitted in diabetic ketoacidosis

Correct Answer: An older patient who is septic, bedridden, and incontinent Rationale: Persons at risk for the development of pressure injuries include those who are older, incontinent, bed or wheelchair bound, or recovering from spinal cord injuries. Other examples of risk factors include diabetes, fever, immobility, and anemia.

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse?Notify the health care provider. Document the fistula formation. Assess the patient and vaginal drainage. Have the UAP apply a dressing to the vagina.

Correct Answer: Assess the patient and vaginal drainage. Rationale: With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse should first assess the patient and drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care provided, describe interventions prescribed, and document the care and patient response.

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 Assessment of the range of motion of the ankle and the patient's activity tolerance

Correct Answer: Assessment of the patient's circulation distal to the location of the dressing Rationale: 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.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching? (Select all that apply.) Take the antibiotic until the wound feels better. Take the analgesic every day to promote adequate rest for healing. Be sure to wash hands before changing the dressing to avoid infection. 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.

Correct Answer: Be sure to wash hands before changing the dressing to avoid infection. 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. 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 postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? Apple Custard Popsicle Potato chips

Correct Answer: Custard Rationale: Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. The other snacks do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid that are also needed for healing.

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

Correct Answer: Debride the nonviable, eschar tissue to allow healing. Rationale: 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 (except for dry, stable necrotic feet or heels). 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 therapy is used to remove drainage and is more likely to be used after debridement.

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? Adhesion Contractions Keloid formation Excess granulation tissue

Correct Answer: Excess granulation tissue 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.

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? Fever and chills Increased blood pressure Increased respiratory rate General malaise and fatigue

Correct Answer: General malaise and fatigue Rationale: An immunosuppressed patient may have the classic symptoms of inflammation or infection masked by the inability to launch a normal immune response. Therefore, in this person, early symptoms may be malaise, fatigue, or "just not feeling 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? Increased platelet count Decreased blood urea nitrogen Increased number of band neutrophils Increased number of segmented myelocytes

Correct Answer: Increased number of band neutrophils Rationale: The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is common 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. Mature neutrophils are segmented.

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

Correct Answer: Intake and output 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.

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage 3 pressure injury? Keep the pressure injury clean and dry. Maintain protein intake of at least 1.25 g/kg/day. Use a 10-mL syringe to irrigate the pressure injury. Irrigate the pressure injury with hydrogen peroxide.

Correct Answer: Maintain protein intake of at least 1.25 g/kg/day. Rationale: Adequate protein intake (between 1.25 and 1.50 g/kg/day) is needed to promote healing of pressure injuries. Hydrogen peroxide is cytotoxic and should not be used to clean pressure injuries. A 30-mL syringe with a 19-gauge needle will provide optimal pressure (4 to 15 psi) without causing tissue trauma or damage. The pressure injury should be kept moist to aid in healing.

The nurse notes a patient has chills related to an infection. What is the priority action by the nurse? Provide a light blanket. Encourage a hot shower. Monitor temperature every hour. Turn up the thermostat in the patient's room.

Correct Answer: Provide a light blanket. Rationale: 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.

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

Correct Answer: Provide acetaminophen every 4 hours to maintain consistent blood levels. 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 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? Serous Purulent Fibrinous Catarrhal

Correct Answer: Purulent 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.

After the unlicensed assistive personnel (UAP) bathed the patient, she reported a reddened area on the patient's coccyx to the nurse. After assessing the area, what should be included in the plan of care? Reposition every 2 hours. Measure the size of the reddened area. Massage the area to increase blood flow. Evaluate the area later to see if it is better.

Correct Answer: Reposition every 2 hours. Rationale: The most important thing to do for this patient is to prevent deterioration of the injury and eliminate factors that led to pressure injuries. This would include eliminating pressure on the reddened area with repositioning every 2 hours in bed and every hour while up in the chair. The nurse must complete the assessment of the new reddened area as well as evaluation of the area. Massage is not used when there is the possibility of damaged blood vessels or fragile skin, so the RN cannot advise the UAP to do this until the RN has assessed the patient and the area.

A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? Warm, moist heat and massage Rest, ice, compression, and elevation Antipyretic and antibiotic drug therapy Active movement and exercise to prevent stiffness

Correct Answer: Rest, ice, compression, and elevation Rationale: Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation. Heat may be applied 24 to 48 hours after the injury.

The nurse assesses impaired skin integrity in this patient. How will the nurse document this? Stage 1 Stage 2 Stage 3 Stage 4

Correct Answer: Stage 3 Rationale: Stage 3 pressure injuries 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 1 injuries have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage 2 injuries are partial thickness with a red-pink wound bed. Stage 4 injuries involve extensive destruction of tissue with exposed bone, tendon, or muscle.

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? Local response Systemic response Infectious response Acute inflammatory response

Correct Answer: Systemic response Rationale: The systemic response to inflammation includes the manifestations of a shift to the left in the 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 2 to 3 weeks and usually leaves no residual damage.

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? White blood cell (WBC) count of 8000/ìL; temperature of 101° F White blood cell (WBC) count of 4000/ìL; temperature of 100° F White blood cell (WBC) count of 8500/ìL; temperature of 98.4° F White blood cell (WBC) count of 16,500/ìL; temperature of 98.8° F

Correct Answer: White blood cell (WBC) count of 8500/ìL; temperature of 98.4° F Rationale: This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/ìL. An elevated WBC count and fever are indicators of infection

Rice= Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation.

Rational Rest Rest helps the body use its nutrients and O2 for the healing process. The repair process is facilitated by allowing fibrin and collagen to form across the wound edges with little disruption. Cold and heat Cold application is usually appropriate at the time of the initial trauma. Use promotes vasoconstriction and decreases swelling, pain, and congestion from increased metabolism in the area of inflammation. Heat may be used later (e.g., after 24 to 48 hours) to promote healing by increasing the circulation to the inflamed site and subsequent removal of debris. Heat is used to localize the inflammatory agents. Warm, moist heat may help debride the wound site if necrotic material is present. Compression and immobilization Compression counters the vasodilation effects and development of edema. Compression by direct pressure over a laceration occludes blood vessels and stops bleeding. Compression bandages support injured joints when tendons and muscles are unable to provide support on their own. Assess distal pulses and capillary refill before and after application of compression to evaluate whether compression has compromised circulation (e.g., pale color of skin, loss of feeling). Immobilization of the inflamed or injured area promotes healing by decreasing the tissues' metabolic needs. Immobilization with a cast or splint supports fractured bones and prevents further tissue injury from sharp bone fragments that could sever nerves or blood vessels, causing hemorrhage. As with compression, evaluate the patient's circulation after application and at regular intervals. Swelling can occur within the closed space of a cast and compromise circulation. Elevation 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. Elevation may be contraindicated in patients with significantly reduced arterial circulation.

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? The wound will be stapled together until it heals.Incorrect Answer The healing will contract the area to close the wound. The wound will be left open and heal from the edges inward. The wound will be sutured after the current infection is controlled.

Your Response: The wound will be stapled together until it heals. Correct Answer: The wound will be left open and heal from the edges inward. Rationale: 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.

serosanguineous drainage

is frequently seen postoperatively and is composed of RBCs and serous fluid so it is a semiclear pink drainage. Serous drainage is a thin, watery drainage. Hemorrhagic drainage is bloody drainage. Purulent drainage consists of WBCs, microorganisms, and other debris that signal an infection.