NR 324 Week 6 Altered Inflammation and Immunity

NR 324 Week 6 Altered Inflammation and Immunity

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Inflammation and Immunity Nursing Care

Altered Inflammation

Preparation: The Nursing Care of Altered Inflammation

Infection and Inflammation

Which of the following statements about infection and inflammation is accurate?

• The terms infection and inflammation are interchangeable.
• Inflammation always accompanies infection.
• Infection is always associated with inflammation.
• Infection and inflammation are not related.

Process of Healing

Adam, a 22-year-old student who enjoys skateboarding, recently fell and fractured his wrist. Following surgery to repair the fracture, Adam’s incision was sutured closed. This scenario exemplifies which type of healing process?

• Primary intention
• Secondary intention
• Tertiary intention

Negative Pressure Wound Therapy

What statement accurately describes negative pressure wound therapy (NPWT)?

• The application of topical medications to dissolve necrotic tissue.
• Removal of significant amounts of nonviable tissue to prepare the wound bed for healing.
• Utilization of a vacuum source to facilitate the removal of fluid, exudate, and infectious debris, promoting healing and closure.

Self-Check: Assessment

When assessing Adam’s surgical incision, which descriptive terms should the nurse incorporate into the assessment note? Select all that apply.

• Hemorrhagic
• Purulent
• Red
• Inflamed
• Necrotic

Self-Check: Adam’s Assessment

During Adam’s fall, he also sprained his ankle. What is the most appropriate intervention for his soft tissue injury?

• Compression with an elastic bandage
• Encouraging early ambulation
• Applying ice to the ankle for 30 minutes

Assessments

Before applying compression to Adam’s ankle, which assessments are crucial for the nurse to complete? Select all that apply.

• Oral temperature
• Passive range of motion (ROM)
• Distal pulses
• Capillary refill
• Blood pressure

The Infectious Process

Which statement made by Adam is the most concerning?

• “My wrist is extremely hot!”
• “My pain is rated 8 out of 10 in my wrist.”
• “I have some watery fluid coming from my incision.”
• “I don’t know if I can move my fingers or wrist anymore.”

Self-Check: Dehiscence Risk Factors

Which factors may increase a client’s risk for wound dehiscence? Select all that apply.

• Obesity
• Cancer
• Diabetes mellitus
• Infection
• Caucasian ethnicity

Reflection: The Nursing Care of Altered Inflammation

Keloid Scarring

Maya, a 24-year-old student, visits her university’s health clinic to inquire about treatment options for keloid scars on her ears and neck. What is the most accurate response from the clinic’s nurse?

• “Your hair conceals the keloid scarring well; why do you feel the need for treatment?”
• “The keloid scarring will eventually diminish, so we will focus on managing your symptoms for now.”
• “The keloid scars can be removed, but there is a possibility they may recur.”

Dietary Requirements

Adam seeks advice from the nurse regarding dietary recommendations to support efficient healing of his injuries. Which suggestion by the nurse is most suitable?

• Consume a diet high in protein and low in vitamins.
• Consume a diet high in protein and high in carbohydrates.
• Consume a diet high in protein and low in carbohydrates.
• Consume a diet high in protein and high in fat.

Delegation

Match the appropriate task to the suitable colleague; some colleagues may be assigned more than once.

Hyperthermia

Upon assessment, the nurse notes that Adam has developed a fever of 102.6°F. Which interventions are most suitable to lower his temperature?

• Administering antipyretics consistently.
• Providing tepid sponge baths.
• Administering prescribed antibiotics.
• Positioning an oscillating fan at Adam’s bedside.

Classifications

Review the client’s nursing notes. Match the client to their respective classification.

Negative Pressure Wound Therapy

A client is receiving negative pressure wound therapy (NPWT) for a dehisced abdominal wound. What important considerations should the nurse be aware of? Select all that apply.

• Place the occlusive dressing in areas with body hair for better adhesion.
• Cut sterile gauze to fit only the center of the wound bed.
• Monitor serum protein levels and fluid and electrolyte balances.
• Avoid placing the occlusive dressing on skin folds and bends.
• Educate the client about the NPWT intervention.

Outcomes and Goals

The nurse identifies a nursing diagnosis of impaired tissue integrity for Adam. Which statements below represent appropriate and realistic goals and outcomes? Select all that apply.

• Adam understands to report any changes in sensation or pain at the site of impaired tissue integrity.
• Adam’s wound is fully healed before discharge and is no longer at risk for impaired tissue integrity.
• Adam demonstrates understanding of his care plan to heal and improve his impaired tissue integrity.
• Adam will increase physical activity of his wrist to promote blood flow to impaired tissue integrity sites.

Wound Dressings

While changing a dressing with the help of a student nurse, the nurse encounters a malodorous wound with purulent and serosanguineous drainage on the old dressing. Which statement from the student nurse requires intervention?

• “Should we give the client pain medication before we begin the dressing change?”
• “How do you handle that unpleasant smell?”
• “Does this type of drainage indicate an infection?”
• “How do you determine what type of dressing to apply?”

Pressure Ulcers

Preparation: Pressure Ulcers

Pressure Ulcer Risk Factors

What common risk factors are associated with the development of pressure ulcers? Select all that apply.

• Incontinence
• Increased temperature
• Obesity
• Renal disease
• Young age

Ulcer Classifications
Which description refers to a stage II pressure ulcer?

• Intact skin with non-blanchable redness over a localized area, typically over a bony prominence.
• Partial thickness loss of dermis with a shallow open ulcer featuring a red pink wound bed without slough.
• Full thickness tissue loss with exposed bone, tendon, or muscle.
• Full thickness tissue loss with visible or palpable bone or muscle.

Common Locations for Pressure Ulcers

Identify common locations for pressure ulcers or sores. Select all that apply.

• Back of the head
• Heels
• Ears
• Coccyx
• Elbows

Self-Check: Nursing Actions – Pressure Ulcer Prevention

Jan has arrived at the medical-surgical unit from the nursing home, where she resides. She has a history of a previous right-sided stroke that left her with musculoskeletal and neurologic deficits. Which nursing actions would be most effective in preventing Jan from developing a pressure ulcer?

• Placing Jan on NPO status
• Reducing protein in her meal trays
• Assisting Jan to reposition every two hours
• Initiating strict bedrest

Self-Check: Suspected Deep Tissue Injury

How can the nurse best assess a client for a suspected deep tissue injury, particularly in clients with darker skin tones?

• Assess the area for temperature changes or consistency.
• Observe for tunneling and undermining.
• Use fluorescent lighting to examine the client’s skin for changes.
• Note that identifying suspected deep tissue injuries in clients with dark skin tones is not possible.

Self-Check: Wound Descriptions

Which description is most suitable for the following wound?

• “Pink wound bed that is moist. Measurements unable to be obtained.”
• “Oval shaped wound bed that is pale with eschar noted at the 12 o’clock position.”
• “Dry pink wound bed approximately 4 cm x 6 cm.”
• “Oval shaped wound bed that is pink and moist, approximately 6 cm x 4 cm with undermining noted from the 12 o’clock to the 1 o’clock position.”

Self-Check: Delayed Wound Healing

Which factors contribute to delayed wound healing? Select all that apply.

• Diabetes mellitus
• High protein intake
• Smoking
• Obesity
• Young age

The nurse assists a student nurse in changing a pressure ulcer dressing on a client’s heel. The nurse should intervene when which action is observed?

• The student wrinkles his nose and grimaces when removing the client’s soiled dressing.
• The student puts on clean gloves before removing the soiled dressing.
• The student cleans the wound bed with sterile 0.9% sodium chloride.
• The student premedicates the client with PRN pain medication before the dressing change.

Reflection: Pressure Ulcers

Ulcer Stages

Match the ulcer stages to the correct descriptions.

Braden Scale

You are caring for Jan, who responds to verbal commands but cannot always communicate her discomfort or need to reposition. You observe that Jan rarely eats a full meal and seldom finishes more than half of her food tray. While she can make slight adjustments to her position occasionally, she requires moderate assistance when moving and often slides down in her bed or chair. Her bed linens are changed at least once a shift due to increased sweating and perspiration. Select Jan’s Braden Scale score values

below.

• Sensory Perception: 2
• Moisture: 2
• Activity: 2
• Mobility: 3
• Nutrition: 2
• Friction and Shear: 2

Total Score: __

References

American Academy of Family Physicians. (2022). Wound care: Negative pressure wound therapy. Retrieved from https://www.aafp.org/pubs/afp/issues/2022/0201/p168.html

Australian Nursing and Midwifery Journal. (2021). Evidence-based practice in wound care. Retrieved from https://anmj.org.au/evidence-based-practice-in-wound-care/

Center for Disease Control and Prevention. (2020). Guidelines for preventing health-care-associated infections. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/index.html

NR 324 Week 6 Altered Inflammation and Immunity

National Institute for Health and Care Excellence. (2019). Pressure ulcers: Prevention and management. Retrieved from https://www.nice.org.uk/guidance/ng89

World Health Organization. (2021). Infection prevention and control. Retrieved from https://www.who.int/health-topics/infection-prevention-and-control