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Questions and Answers
What is the initial phase of the inflammatory response?
What is the initial phase of the inflammatory response?
Which symptom is NOT typically associated with inflammation?
Which symptom is NOT typically associated with inflammation?
Which type of exudate is characterized by a high protein content and is often seen in inflammatory responses?
Which type of exudate is characterized by a high protein content and is often seen in inflammatory responses?
What is a key nursing action in managing a patient with fever related to infection?
What is a key nursing action in managing a patient with fever related to infection?
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In the reparative phase of inflammation, which process primarily occurs?
In the reparative phase of inflammation, which process primarily occurs?
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What differentiates acute inflammation from chronic inflammation?
What differentiates acute inflammation from chronic inflammation?
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Which of the following agents is primarily responsible for causing vasodilation during the vascular response in inflammation?
Which of the following agents is primarily responsible for causing vasodilation during the vascular response in inflammation?
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Which of the following is NOT a characteristic of the inflammatory response?
Which of the following is NOT a characteristic of the inflammatory response?
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What is the term for the removal and destruction of bacteria by phagocytic cells during the inflammatory response?
What is the term for the removal and destruction of bacteria by phagocytic cells during the inflammatory response?
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Which type of exudate is characterized by the presence of dead neutrophils and digested bacteria?
Which type of exudate is characterized by the presence of dead neutrophils and digested bacteria?
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Which of the following is NOT a characteristic of acute inflammation?
Which of the following is NOT a characteristic of acute inflammation?
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What is the expected temperature indicating systemic inflammation?
What is the expected temperature indicating systemic inflammation?
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During the reparative phase of inflammation, what type of tissue appears pink or red?
During the reparative phase of inflammation, what type of tissue appears pink or red?
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Which assessment cue would NOT be classified as a localized sign of inflammation?
Which assessment cue would NOT be classified as a localized sign of inflammation?
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What may result from the persistence of an injurious agent in the body?
What may result from the persistence of an injurious agent in the body?
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Which of the following components does NOT contribute to the accumulation of pain during inflammation?
Which of the following components does NOT contribute to the accumulation of pain during inflammation?
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What is a key characteristic of the acute inflammatory response?
What is a key characteristic of the acute inflammatory response?
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Which of the following types of exudate indicates a strong inflammatory response and is typically associated with bacterial infections?
Which of the following types of exudate indicates a strong inflammatory response and is typically associated with bacterial infections?
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What is the goal of nursing care when managing a patient with cellulitis?
What is the goal of nursing care when managing a patient with cellulitis?
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In the management of fever, which of the following medications is an antipyretic that inhibits prostaglandin synthesis?
In the management of fever, which of the following medications is an antipyretic that inhibits prostaglandin synthesis?
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What distinguishes chronic inflammation from acute inflammation?
What distinguishes chronic inflammation from acute inflammation?
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What is one of the main complications of fever in older adults?
What is one of the main complications of fever in older adults?
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Which of the following dietary components may help reduce inflammation?
Which of the following dietary components may help reduce inflammation?
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Which laboratory test is most commonly used to evaluate the presence of inflammation?
Which laboratory test is most commonly used to evaluate the presence of inflammation?
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What vital signs indicate a possible infection or inflammation in a patient?
What vital signs indicate a possible infection or inflammation in a patient?
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Which action is crucial for a nurse to teach a patient with a skin wound to minimize the risk of infection?
Which action is crucial for a nurse to teach a patient with a skin wound to minimize the risk of infection?
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Study Notes
Week 13: Inflammation and Infection
- Infection: Invasion of body tissue by microorganisms, potentially causing disease or illness.
- Inflammation: Physiological response to reduce the effects of perceived harmful substances, a non-specific reaction.
Competencies
- Define patient-centered, evidence-based care using the nursing process.
- Discuss factors creating a culture of safety in caring for patients with common health alterations.
- Discuss health promotion, maintenance, illness & injury prevention, and healing facilitation.
- Discuss critical thinking use to prioritize patient care elements during nursing process implementation.
- Discuss critical thinking strategies used in making clinical judgments.
- Discuss roles of interprofessional collaborative practice members.
Inflammation Defense against Infection
- Adaptive response to illness or injury.
- Brings fluid (plasma), dissolved substances, and blood cells to interstitial tissue where invasion or damage occurred.
- First phase of the healing process.
- Non-specific.
Inflammation ≠ Infection
- Pain
- Swelling
- Redness
- Heat
- Impaired function
Inflammatory Response Stages
-
Stage 1: Vascular and Cellular Response
- Cell injury triggers release of histamines, prostaglandins, and kinins.
- Blood vessels dilate, increasing blood supply to the site (hyperemia).
- Vasoconstriction (transient) followed by vasodilation.
- Histamine, prostaglandins, and kinins are released.
- Redness appears.
- Increased vascular permeability allows fluid, proteins, and leukocytes to leak into the interstitial space, causing edema.
- Leukocytes accumulate at the site and initiate the clotting response.
- Pain is from fluid accumulation and chemical release, causing swelling (edema).
- Examples of injuries: sprains, minor burns, broken bones.
-
Stage 2: Exudate Response
- Exudate (fluid escaping blood vessels) contains tissue cells, phagocytic cells, and their byproducts.
- Phagocytosis: removal/destruction of bacteria (ingestion).
- Types of exudate: Serous, Purulent, Hemorrhagic.
-
Stage 3: Reparative Phase
- Replacement/repair of injured tissues.
- Granulation tissue forms, which appears pink or red and is fragile.
- Damaged cells are replaced one by one
- If regeneration is not possible, repair occurs via fibrous tissue (scar).
Infection Diagnostics
- CBC: Complete Blood Count
- ESR: Erythrocyte Sedimentation Rate
- CRP: C-Reactive Protein
Nursing Care and Collaborative Management
- Health promotion/teaching
- Preventing injuries
- Providing proper nutrition (omega-3 fatty acids, probiotics, antioxidants, decreasing saturated fats, cholesterol, high glycemic index).
- Early recognition of inflammation.
- Prompt treatment.
Nursing Care Management (RICE)
- Rest: The injured area for 48 hours.
- Ice: Apply for 20 minutes at a time, 4-8 times per day.
- Compress: To reduce swelling.
- Elevate: Injured limb 6-10 inches above the heart.
Infection Concept
- Invasion of body tissue by microorganisms with the potential to cause illness or disease.
Susceptible Host factors
- Elderly
- Infants
- Immunocompromised
- ANYONE
Portal of Entry
- Mouth
- Nose
- Eyes
- Cuts in skin
Mode of Transmissions for Infections
- Direct contact
- Indirect contact
- Vectors
Portal of Exit
- Coughing/Sneezing
- Bodily Secretions
- Feces
Cellulitis
- Inflammation of subcutaneous tissues (often following a skin break).
- Deep inflammation of the subcutaneous tissue is from bacterial enzymes.
- Common organisms: Staphylococcus aureus, Streptococci
- Signs & Symptoms: Warm or hot to touch, Redness, Swollen, Fever/chills, Lethargy, Discomfort, Lymph node enlargement.
Assessment
- Recognize infection
- Document location, trace border.
- Assess for symptoms
- Vital signs
- Precipitating factors
- Monitor for sepsis, gangrene.
Planning
- Set goals (minimizing infection, managing pain)
- Education
Nursing Implementation
- Rest
- Encourage oral hydration
- Elevation
- Comfort measures (possible moist heat - need order)
- Hand hygiene; wound care; prevention, reporting, symptoms
- Medications (antibiotics).
Antibiotics (Collaborative Practice)
- Improvement should be seen within 3 days.
- Antibiotics should continue in most cases 5 to 14 days.
- Encourage oral hydration.
- Patients should complete the prescribed course of antibiotics unless an adverse response occurs.
Teaching
- Wash hands before touching the wound.
- Wash the wound daily with soap and water.
- Topical Antibiotics (may be ordered).
- Monitor for signs (infection, increased fever, pain, redness).
- Report if signs or symptoms worsen.
Differential Assessment
- Examine for signs and symptoms associated with inflammation & infection to differentiate various conditions.
Skin Assessment - Deeper Pigmentation
- Erythema: red hue, hyper or darker pigmentation, or darker blue hues.
Important Note
- Inflammation is always present with an infection, but infection is not always present with inflammation.
Fever (Pyrexia)
- Systemic response to infection, increase in body temperature.
Physiology of Fever
- Cellular metabolism increases
- Increases heat production
- Oxygen needs increase
- Cellular hypoxia (can cause angina, confusion)
- Energy stores become depleted (fatigue)
- Pulse and respirations increase; diaphoresis (sweating) occurs.
- Dehydration.
Fever Management
- Beneficial aspects include killing microorganisms and increased phagocytosis.
- Antipyretic drugs inhibit prostaglandin synthesis (e.g., salicylates, acetaminophen, NSAIDs).
Fever in the Older Adult
- Older adults are sensitive to temperature extremes.
- Deterioration in vasomotor control of vasoconstriction and vasodilation.
- Reduced subcutaneous tissue, sweat gland activity, and metabolism.
- Dehydration resulting from elevated temperature can be serious, potentially fatal.
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Description
Explore the critical concepts of inflammation and infection in nursing. This quiz covers the physiological responses to harmful substances and highlights the importance of evidence-based care while prioritizing patient needs. Gain insights into the roles of interprofessional collaboration and the nursing process in patient treatment.
