NR 324 Week 6 Altered Inflammation and Immunity
Student Name
Chamberlain University
NR-324 Adult Health I
Prof. Name
Date
Week 6: Altered Inflammation and Immunity
Nursing Care of Altered Inflammation
This week’s focus is on managing altered inflammation and immunity, including wound healing, infection recognition, pressure ulcer management, and related nursing interventions.
Infection and Inflammation
Which statement regarding infection and inflammation is correct?
The correct answer is: Inflammation is always present with infection. While infection and inflammation are closely related, they are not synonymous. Infection refers to the invasion of tissues by microorganisms, while inflammation is the body’s response to harmful stimuli. Inflammation can occur without infection, such as in autoimmune disorders.
Process of Healing
Adam’s Case Study:
Adam, a 22-year-old skateboard enthusiast, suffered a wrist fracture and underwent surgical repair. His sutured incision is an example of healing by primary intention, where the wound edges are closely approximated, minimizing tissue loss and scarring.
Negative Pressure Wound Therapy (NPWT)
Which statement best describes negative pressure wound therapy (NPWT)?
NPWT involves a vacuum-assisted device that promotes the removal of fluids, exudates, and infectious materials to enhance healing and wound closure. This method facilitates granulation tissue formation and reduces wound size.
Self-Check: Assessment
Which descriptive words would be appropriate in Adam’s assessment note?
Appropriate terms include:
- Red
- Inflamed
- Purulent
These words help describe common signs of inflammation and possible infection.
Self-Check: Adam’s Soft Tissue Injury
Most appropriate intervention for soft tissue injury?
Ice application for 30 minutes is ideal in the initial phase of a soft tissue injury to reduce swelling and pain.
Assessments Prior to Compression
Important assessments before applying compression:
| Required Assessments | Not Required |
|---|---|
| Distal pulses | Oral temperature |
| Capillary refill | Passive ROM |
| Blood pressure |
These assessments ensure adequate circulation before applying compression devices.
The Infectious Process
Most concerning statement made by Adam:
“I don’t know if I can move my fingers or wrist anymore.”
This could indicate compartment syndrome or nerve involvement, requiring immediate medical attention.
Self-Check: Dehiscence Risk Factors
Which factors increase the risk of wound dehiscence?
- Obesity
- Cancer
- Diabetes mellitus
- Infection
These factors impair wound healing by affecting tissue integrity and immune response.
Reflect: The Nursing Care of Altered Inflammation
Keloid Scarring
Most accurate statement by the nurse:
“The keloid scarring can be removed, but it may come back.”
Keloids are overgrowths of scar tissue and may recur even after treatment.
Dietary Requirements
Appropriate dietary recommendation for healing:
Eat a diet high in protein and high in carbohydrates.
This combination promotes tissue repair and energy replenishment.
Delegation: Matching Tasks
Match each task to the most appropriate staff member:
| Task | Appropriate Colleague |
|---|---|
| Taking vital signs | Nursing Assistant |
| Administering IV antibiotics | Registered Nurse (RN) |
| Assisting with ambulation | Unlicensed Assistive Personnel (UAP) |
| Dressing changes | RN or Licensed Practical Nurse (LPN) |
Hyperthermia
Interventions for reducing fever:
- Administer antipyretics around the clock
- Provide tepid sponge baths
- Place an oscillating fan at bedside
These interventions help manage hyperthermia by promoting heat loss.
Classifications: Nurse Notes
Match patient cases with classification types (example only):
| Classification | Patient Presentation |
|---|---|
| Stage II Pressure Ulcer | Shallow ulcer with red-pink wound bed |
| Suspected Deep Tissue Injury | Discoloration under intact skin |
| Primary Intention Healing | Surgical incision with approximated edges |
Negative Pressure Wound Therapy: Key Points
Important aspects of NPWT:
- Monitor serum protein and fluid/electrolyte levels
- Avoid placing dressing on skin folds or hair-covered areas
- Provide thorough client education
- Cut gauze to fit the wound bed correctly
These measures promote effective therapy and reduce complications.
Outcomes and Goals
Realistic outcomes for impaired tissue integrity:
- Adam reports any new pain or altered sensation
- Adam demonstrates understanding of wound care
Setting achievable and measurable goals ensures proper evaluation of healing.
Wound Dressings
Which student nurse statement requires intervention?
“How do you deal with that gross smell?”
This remark is unprofessional and lacks empathy. Nurses must maintain a respectful demeanor at all times.
Pressure Ulcers
Risk Factors
Common pressure ulcer risk factors include:
- Incontinence
- Obesity
- Renal disease
Ulcer Classifications
Stage II pressure ulcer characteristics:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough.
Common Ulcer Locations
| Pressure Points |
|---|
| Back of the head |
| Heels |
| Ears |
| Coccyx |
| Elbows |
Self-Check: Nursing Actions – Pressure Ulcer Prevention
Most helpful nursing action for Jan:
Assisting Jan to reposition every two hours.
Frequent repositioning reduces pressure on vulnerable skin areas and promotes circulation.
Self-Check: Suspected Deep Tissue Injury
Best assessment technique for darker skin tones:
Use palpation and comparison with surrounding tissues to assess temperature, firmness, and skin texture. Visual cues alone may not be sufficient.
Skin and Wound Assessment
Assess the Area for Changes in Temperature or Consistency
When assessing a patient’s skin for pressure injuries, it is essential to observe the area for any abnormal changes in temperature or consistency. Increased warmth may indicate inflammation or infection, while hardness can suggest deep tissue injury (DTI). Nurses should palpate the area gently to detect these differences.
Observe for Tunneling and Undermining
Tunneling refers to channels that extend from the wound into surrounding tissue, while undermining is tissue destruction underlying intact skin around the wound edges. These can be identified using a sterile cotton applicator to gently explore the wound perimeter. Document any findings with specific clock-face references (e.g., undermining noted from 12 to 3 o’clock).
Use Fluorescent Lighting for Skin Assessment
Fluorescent lighting enhances visibility, helping detect subtle changes in skin tone, moisture, or injury, especially for patients with darker skin tones.
Deep Tissue Injuries in Clients with Dark Skin Tones
Suspected deep tissue injuries (sDTIs) may be more difficult to identify in individuals with darker skin. Look for signs such as localized temperature differences, firmness, pain, or bogginess instead of just discoloration.
Self-Check: Wound Descriptions
Which of the following descriptions is best for this wound?
Answer: “Oval shaped wound bed that is pink and moist, approximately 6 cm x 4 cm with undermining noted at the 12 o’clock to 1 o’clock position.” This description includes color, shape, moisture, measurement, and undermining, which are all essential wound documentation elements.
Self-Check: Delayed Wound Healing
Which factors delay wound healing?
| Factors That Delay Healing | Impact on Healing |
|---|---|
| Diabetes Mellitus | Impairs circulation and immune response |
| Smoking | Reduces oxygen supply and delays tissue repair |
| Obesity | Increases pressure and impairs perfusion |
Incorrect options: High protein intake and young age generally promote healing.
Observing Nursing Practice
Which student nurse action needs intervention?
Answer: “The student wrinkles his nose and makes a funny face when removing the client’s soiled dressing.” This is unprofessional behavior and could make the patient feel embarrassed or ashamed.
Reflect: Pressure Ulcers
Ulcer Stages Table
| Ulcer Stage | Description |
|---|---|
| Stage I | Non-blanchable erythema of intact skin |
| Stage II | Partial-thickness skin loss with exposed dermis |
| Stage III | Full-thickness skin loss, possibly with slough |
| Stage IV | Full-thickness tissue loss with exposed bone/tendon |
Braden Scale Assessment for Jan
Based on Jan’s condition:
| Category | Score |
|---|---|
| Sensory Perception | 2 |
| Moisture | 2 |
| Activity | 1 |
| Mobility | 2 |
| Nutrition | 2 |
| Friction/Shear | 2 |
| Total Score | 11 (High risk) |
Prevention
Recommendations to prevent pressure ulcers:
- Reposition Jan frequently in bed and transfer to a chair.
- Assist Jan to the bathroom every two hours.
- Request a pressure-relieving mattress.
Incorrect options: Excessive blankets and daily bathing are not beneficial and may cause harm.
Nursing Diagnosis
What led to the diagnosis of impaired skin integrity?
| Contributing Factors |
|---|
| Moisture |
| Advanced age |
| Impaired mobility |
| Decreased nutritional intake |
Goals of Care
Which goal is best for Jan?
Answer: “Skin will remain intact and present pressure ulcers will not worsen.” This is a measurable and relevant outcome.
Complication: Exudate Description
How should Jan’s wound exudate be documented?
Answer: Purulent – indicates thick, yellow-tan fluid with a foul odor, typically associated with infection.
Dressing Change Supplies
Required items for Jan’s dressing change:
- Gloves
- Measuring device
- Cotton tipped applicators
- PPE (gown, mask, gloves)
Incorrect: Warm lactated Ringer’s is not standard wound irrigation fluid.
Prescription Prior to Dressing Change
Answer: Administer 5 mg oxycodone PO every 3–4 hours as needed. Pain management is crucial before dressing changes.
Altered Immune Response
Artificial Passive Acquired Immunity
Best example: Immunoglobulin IV – provides immediate but short-term immunity.
Immunoglobulin Response to Allergens
Correct immunoglobulin: IgE – increases during allergic responses.
Active Acquired Immunity
Best example: Immunization – activates the immune system to build long-term protection.
Natural Passive Immunity
Best example: Breastfeeding – maternal antibodies are passed to the infant.
Diagnostic Studies for Allergies
Correct test: Sputum culture – helps identify pathogens in the respiratory system.
Assessment Data for Allergic Reactions
| Risk Factors |
|---|
| Asthma |
| Penicillin allergy |
| Egg allergy |
Incorrect: Renal failure and hypertension are not direct allergic risk factors.
Pharmacologic Management
Inflammation reducer post-albuterol: Corticosteroids
Stabilizing medication for low BP post-allergic reaction: 0.9% NaCl IV infusion
Reflect: Apheresis and Immune Response
Leukocyte removal procedure: Leukocytapheresis
Nursing Actions for Bee Sting Allergy
| Appropriate Interventions |
|---|
| Monitor VS and LOC |
| Administer epinephrine |
| Reposition to supine |
Incorrect: Calcium carbonate and pantoprazole are not related to acute allergic reactions.
Citrate Toxicity
Electrolyte imbalance caused: Hypocalcemia
Complications of Plasmapheresis
| Common Complications |
|---|
| Citrate toxicity |
| Hypothermia |
| Hypotension |
Organ Donation and Transplant
Transplantable Organs: Heart, Lungs, Liver (not Brain)
Most common anaphylactic complication: Cardiogenic shock
Legal signer for cornea donation if client not an organ donor: Legal guardian
Transplant rejection within 24 hrs: Hyperacute rejection
HIV and Immune Deficiency
HIV Clinical Manifestations
| Symptoms |
|---|
| Lethargy |
| Diarrhea |
| Fever |
Incorrect: Weight gain and constipation are not typical initial symptoms.
Common HIV Complications
| Conditions |
|---|
| Chronic bronchitis |
| Guillain-Barre syndrome |
| Aseptic meningitis |
Risk Factors for HIV
| Risk Behaviors |
|---|
| Unprotected sex |
| Sharing needles |
HIV Transmission Modes
| Modes of Transmission |
|---|
| Sexual contact |
| Infected blood |
| Breastfeeding |
Nursing Diagnoses Based on Lifestyle
| Applicable Diagnoses |
|---|
| Risk for infection |
| Knowledge deficit |
| Powerlessness |
Health Teaching for Visitors
Appropriate response: HIV can be transmitted through many means including sexual contact, infected blood, or breast milk.
Teaching for Partner Protection
Most appropriate: Encourage partner to take PrEP treatment.
Acute HIV Infection Finding
Answer: Elevated viral load – typically found in acute HIV infections.
Reflect and Care Management
Nursing actions based on patient’s low BP, elevated viral load, and WBC count of 3000:
- Administer 250 ml NaCl IV bolus
- Oxygen therapy at 2 L/min
- Monitor VS and LOC
- Reinforce neutropenic precautions
Nursing Diagnoses
| Diagnosis |
|---|
| Fluid volume deficit |
| Risk for infection |
| Impaired gas exchange |
Neutropenic Precaution
Best practice: Wear surgical mask to minimize respiratory droplet exposure.
AIDS Confirmation
Diagnostic value: CD4 T cell count below 200/microliter
Hepatitis B & C with HIV
Precaution: Standard precautions
Medication Compliance Support
Nursing Action: Give pillbox with days labeled and set alarms in personal phone.
Therapeutic Communication
Correct response: Can you tell me more about your feelings of hopelessness?
Prevention in Asymptomatic HIV
| Recommended Vaccinations |
|---|
| Hepatitis vaccine |
| Influenza vaccine |
| Pneumococcal vaccine |
References
Centers for Disease Control and Prevention. (2023). HIV basics. https://www.cdc.gov/hiv/basics/index.html
Ignatavicius, D. D., & Workman, M. L. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier.
Nursing and Midwifery Council. (2020). Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates.
NR 324 Week 6 Altered Inflammation and Immunity
Potter, P. A., & Perry, A. G. (2021). Fundamentals of nursing (11th ed.). Elsevier.American Nurses Association. (2022). Nursing: Scope and standards of practice (4th ed.).
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of nursing (10th ed.). Elsevier.
NR 324 Week 6 Altered Inflammation and Immunity
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2020). Brunner & Suddarth’s textbook of medical-surgical nursing (15th ed.). Wolters Kluwer Health.