Inflammation and Healing

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Which of the following is the correct sequence of events in the vascular response phase of the inflammatory response after a cell injury?

Increased capillary permeability, vasodilation, brief vasoconstriction.
Vasodilation, brief vasoconstriction, increased capillary permeability.
Brief vasoconstriction, vasodilation, increased capillary permeability. (correct)
Vasodilation, increased capillary permeability, brief vasoconstriction.

Why is the formation of a clot at the site of inflammation beneficial?

It immediately generates new epithelial tissue to close the wound.
It prevents the migration of macrophages to the injury site.
It traps bacteria, prevents their spread, and provides a framework for healing. (correct)
It dissolves bacteria and reduces inflammation directly.

A patient's lab results indicate a 'shift to the left' in their WBC differential. What does this usually signify?

A chronic viral infection.
An allergic reaction.
A parasitic infestation.
An acute bacterial infection. (correct)

How do monocytes contribute to the healing process during the cellular response phase of inflammation?

By transforming into macrophages that phagocytize inflammatory debris. (C) Signup and view all the answers

What is the primary role of the complement system in the inflammatory response?

To mediate inflammation, destroy invading pathogens and induce cellular lysis. (A) Signup and view all the answers

How do corticosteroids work to reduce inflammation?

By inhibiting the conversion of arachidonic acid into prostaglandins and leukotrienes. (B) Signup and view all the answers

Why does administering antipyretics at regular intervals help manage fever?

To prevent acute swings in temperature by maintaining a consistent drug level. (C) Signup and view all the answers

What is the rationale behind using rest as part of the RICE (Rest, Ice, Compression, Elevation) treatment strategy for inflammation?

Rest reduces the metabolic needs of the tissues, allowing more oxygen and nutrients to promote healing. (D) Signup and view all the answers

Which type of healing intention is characterized by extensive tissue loss, wide irregular margins, and granulation from the edges inward and from the bottom up?

Secondary intention. (B) Signup and view all the answers

In wound healing by primary intention, what is the role of the clot that forms in the initial phase?

To provide a matrix for WBC migration and capillary growth. (C) Signup and view all the answers

What is the main characteristic of the maturation phase of wound healing by primary intention?

Organization of collagen and increased scar strength. (D) Signup and view all the answers

A patient who is post-operative develops a wound infection. The surgeon decides to leave the wound open to heal, and suture it closed at a later date. Which type of healing intention is this?

Tertiary intention. (B) Signup and view all the answers

How does negative-pressure wound therapy (NPWT) promote wound healing?

By removing fluid, exudate, and bacteria, and enhancing blood flow to the wound base. (C) Signup and view all the answers

What is the primary mechanism by which hyperbaric oxygen therapy (HBOT) enhances wound healing?

Stimulating angiogenesis and improving WBC function via increased oxygen diffusion into the serum. (B) Signup and view all the answers

Why is it important to rotate a culture swab over a cleansed area 1-cm² near the center of the wound with enough pressure to extract wound fluid from deep tissue layers and send to the lab within 30 minutes?

To ensure the sample contains representative microorganisms from the deeper tissues. (A) Signup and view all the answers

In an acute care setting, what intervention should be avoided for a patient with blanchable erythema?

Turning the patient onto the skin exhibiting the blanchable erythema. (D) Signup and view all the answers

Why is dry, stable necrotic tissue on the feet or heels typically not debrided?

The stable eschar serves as a protective barrier, and removal could introduce infection or worsen the wound. (A) Signup and view all the answers

A patient with a Stage 3 pressure injury and a history of immunosuppression shows no classic signs of infection. What is the MOST appropriate action?

Closely monitor the wound for subtle changes and consider lab work, due to the potential for atypical presentation of infection. (C) Signup and view all the answers

A patient is being discharged after treatment for a pressure injury. What key education point should be emphasized to the patient and their caregiver to prevent recurrence?

The etiology of pressure injuries, risk factors, prevention techniques, early signs, nutritional support, and proper care techniques. (B) Signup and view all the answers

What is the recommended daily protein intake for a patient with a pressure injury needing nutritional support?

1.25 to 1.50 g of protein/kg/day (A) Signup and view all the answers

A patient in acute care has a pressure injury with blanchable erythema. Which intervention should be avoided?

Turning the patient onto the skin with the blanchable erythema. (D) Signup and view all the answers

In acute care for a pressure injury, what principle should guide wound bed management, excluding dry, stable necrotic areas?

Maintain a moist wound bed to facilitate healing. (D) Signup and view all the answers

For a patient with a Stage 3 pressure injury, what nutritional support strategy is most appropriate, assuming no specific contraindications?

Provide a caloric intake of 30-35 calories/kg/day and 1.25-1.50 g of protein/kg/day. (A) Signup and view all the answers

A patient is being discharged after treatment for a pressure injury. What key educational point should be emphasized to both the patient and their caregiver to prevent recurrence?

Techniques for pressure redistribution and early signs of skin breakdown. (B) Signup and view all the answers

What is the primary expected outcome when evaluating the care of a patient with a pressure injury?

The pressure injury shows signs of healing, and the surrounding skin remains intact. (B) Signup and view all the answers

A patient is admitted with a suspected deep tissue injury on their heel. Which assessment finding would be most indicative of this type of injury?

The skin is intact but has a localized area of non-blanchable deep red, maroon, or purple discoloration. (C) Signup and view all the answers

A patient with a medical device-related pressure injury caused by a splint on their lower leg. What is the most important nursing action to prevent further injury?

Ensure the splint is applied according to the manufacturer's instructions and assess the skin regularly. (A) Signup and view all the answers

Which of the following assessment findings would suggest that a patient's pressure injury is infected?

Redness and warmth around the wound with purulent drainage and a fever. (B) Signup and view all the answers

A patient has developed a Stage 3 pressure injury on their coccyx during a long hospitalization. What is the most appropriate initial action?

Report the pressure injury as a serious reportable event. (A) Signup and view all the answers

When assessing a dark-skinned patient for pressure injuries, what technique is most important to accurately identify potential tissue damage?

Look for areas of skin that are darker (purplish, brownish, bluish) than the surrounding skin, using natural or halogen light. (C) Signup and view all the answers

An elderly patient is being admitted to a long-term care facility. Which action is most important for the nurse to perform regarding pressure injury prevention?

Perform and document a thorough head-to-toe skin assessment on admission. (A) Signup and view all the answers

A patient is at high risk for developing pressure injuries. Which nursing intervention is the most effective in preventing their formation?

Implementing a regular turning and repositioning schedule. (D) Signup and view all the answers

Which of the following complications is most likely to occur if a pressure injury is left untreated?

Cellulitis or osteomyelitis. (C) Signup and view all the answers

A nurse notes that a patient's previously Stage 2 pressure injury is now covered with eschar. How should the nurse classify this pressure injury?

Unstageable. (D) Signup and view all the answers

Which interprofessional team member would be most beneficial to consult for a patient with a large, complex pressure injury to optimize wound healing?

Wound, Ostomy, Continence (WOC) nurse. (C) Signup and view all the answers

A patient is admitted with a suspected deep tissue injury. Which assessment finding is most consistent with this type of injury?

Intact skin with a localized area of non-blanchable deep red, maroon or purple discoloration. (B) Signup and view all the answers

Which of the following is a key characteristic of a medical device-related pressure injury?

Conforms to the pattern or shape of the device. (D) Signup and view all the answers

Which of the following assessment findings would indicate a localized infection in a pressure injury?

Increased wound size, odor, purulent drainage. (C) Signup and view all the answers

What is the most common complication associated with pressure injuries?

Recurrence. (B) Signup and view all the answers

A Stage 3 pressure injury develops after a patient is admitted to a healthcare facility. According to the guidelines presented, what action should the nurse take?

Report the injury as a Serious Reportable Event (SRE). (C) Signup and view all the answers

When assessing a patient with dark skin for pressure injuries, what is the best lighting to use for accurate assessment?

Natural or halogen lighting. (C) Signup and view all the answers

What sensation reported by a patient with dark skin may indicate a Stage 1 pressure injury?

Pain or an itchy sensation. (A) Signup and view all the answers

What is the primary nursing responsibility in preventing pressure injuries?

Identification of patients at risk and implementation of prevention strategies. (A) Signup and view all the answers

Which interprofessional team member would be MOST helpful in addressing a patient's nutritional needs to promote wound healing?

Dietician. (D) Signup and view all the answers

A nurse is palpating the skin around a suspected pressure injury and notes that the tissue feels soft and yielding, like it contains fluid underneath. How should the nurse document this finding?

Boggy. (C) Signup and view all the answers

Which of the following is the primary purpose of the inflammatory response?

To neutralize harmful agents, remove damaged tissue, and create an environment for healing. (A) Signup and view all the answers

During the vascular response phase of inflammation, what physiological change leads to the characteristic signs of redness and heat?

Vasodilation resulting from chemical mediators released by injured cells. (A) Signup and view all the answers

How does fibrinogen contribute to the inflammatory response?

By transforming into fibrin, which strengthens blood clots and traps bacteria. (A) Signup and view all the answers

What is the significance of a 'shift to the left' in the context of a complete blood count during inflammation?

It reflects an increase in immature neutrophils (bands), indicating an acute bacterial infection. (A) Signup and view all the answers

How do macrophages contribute to the resolution of the inflammatory response?

By phagocytizing inflammatory debris, cleansing the area to facilitate healing. (B) Signup and view all the answers

Which of the following chemical mediators is responsible for the bronchoconstriction and increased capillary permeability seen in anaphylaxis?

Leukotrienes (C) Signup and view all the answers

How do nonsteroidal anti-inflammatory drugs (NSAIDs) reduce inflammation?

By inhibiting the conversion of arachidonic acid into prostaglandins and leukotrienes. (B) Signup and view all the answers

A patient has local manifestations of inflammation. Which of the following would you expect to observe?

Redness, heat, swelling and pain. (B) Signup and view all the answers

What is the rationale for using antipyretics to manage a fever?

To block the action of cytokines and prostaglandins on the hypothalamus, lowering the body's set point. (D) Signup and view all the answers

Why is rest recommended as part of the RICE (Rest, Ice, Compression, Elevation) approach to managing inflammation?

To minimize oxygen and nutrient demand in the injured area, promoting tissue repair. (C) Signup and view all the answers

What is the key difference between healing by primary intention and secondary intention?

Primary intention involves approximated wound edges, while secondary intention involves wide, irregular wound margins. (B) Signup and view all the answers

In wound healing, what is the role of fibroblasts during the granulation phase?

To secrete collagen, which forms the scar tissue and strengthens the wound. (A) Signup and view all the answers

Which of the following factors can delay wound healing?

Corticosteroid use and anemia. (B) Signup and view all the answers

What is the primary mechanism by which negative-pressure wound therapy (NPWT) promotes wound healing?

Removing excess fluid, exudate, and bacteria while enhancing blood flow. (D) Signup and view all the answers

Which of the following is the most important factor in preventing pressure injuries?

Frequent repositioning to relieve pressure (D) Signup and view all the answers

Pressure Injury: Positioning

In acute care, avoid positioning patients directly on skin showing blanchable erythema (redness that turns white with pressure).

Wound Debridement

Wound debridement involves removing dead or damaged tissue, except in the case of dry, stable necrotic tissue on the feet or heels.

Infection Risk in Pressure Injuries

Stages 2-4 pressure injuries are usually contaminated or colonized with bacteria. Be aware that symptoms of infection may be subtle or absent, especially in those with chronic wounds or weakened immunity.

Nutritional Support for Healing

Individuals with pressure injuries need a high intake to promote healing. This often means 30-35 calories/kg/day and 1.25-1.50 g of protein/kg/day.