inflammatory response
is sequential reaction to cell injury
-it neutralized and dilutes the inflammatory agent, removes necrotic materials, and establishes an environment
suitable for healing and repair.
'inflammation is always present w infection, but infection is not always present w inflammation
...
infection
involves invasion of tissues or cells by microorganisms such as bacteria,fungi, and viruses.
infection can also be caused by ________
-heat, radiation, trauma, chemicals, allergens, and autoimmune reaction.
inflammatory response can be divided into______
vascular response,cellular response, formation of exudate, and healing
vascular response
...
cellular response
-neutrophils and monocytes move from circulation to the site of injury.
chemotaxis
is directional is the migration of WBCs to the site of injury, resulting in an accumulation of neutrophils and monocytes at the site.
neutrophils
are the first leukocytes to arrive at the injury site (usually within 6-12 hrs.
- they phagocytize (engulf) bacteria, other foreign material and damaged cells.
-short life span of (24-48hrs) dead neutrophils accumulate.
Pus
-mixture of dead neutrophils, digested bacteria, and other cell debris accumulates as a creamy substance.
Elevated WBC
#NAME?
bands
-immature neutrophils released by the bone marrow into the circulation. (because of the demand)
segmented neutrophils
mature neutrophils
shift to left
the finding of increased number of band neutrophils in circulation.
-commonly found in pts w acute bacterial infections
monocytes
-second type of phagocytic cells that migrate from circulating blood.
-they usually arrive at the site within 3-7 days after the onset of inflammation.
-monocytes transform into macrophages when entering tissue spaces.
macrophages
assist in phagocytosis of the inflammatory debris.
-cleaning of the area before healing can begin.
-have long life span. they can multiply and may stay in the damaged tissues for weeks.
histamine
-stored in granules of basophils, mast cells, platelets
-causes vasodilation and increased capillary permeability
local manifestations of inflammation
Redness-hyperemia from vasodilation
heat- (calor) increased metabolism at the inflammatory site
pain- (dolor) changed in pH. nerve stimulation by chemicals
(e.g histamine,prostaglandings) pressure from fluid exudate
swelling-(tumor) fluid shift to interst
systemic manifestations of inflammation
-increased WBC count w shift to left,malaise, nausea, and anorexia, increased pulse and resp rate and fever.
acute inflammation
the healing that occurs in 2 to 3 weeks and usually leaves no residual drainage .
-neutrophils are predominant cell type at the site
subacute inflammation
has the features of the acute process but lasts longer.
-ex: infective endocarditis is a smoldering infection w acute features but lasts longer up to weeks or months
chronic inflammation
lasts for weeks, months or even years. the injurious agent persists or repeatedly injures tissue.
-predominant cell types are macrophages or lymphocytes.
ex; rheumatoid arthritis and osteomyelitis.
- the prolongation of inflammation may be the result of a
adequate nutrition
-is essential so that the body has necessary factors to promote healing when injury occurs.
-high fluid intake is needed to replace fluid loss from perspiration.
vital signs (acute care) inflammation
-taking corticosteroids or receiving chemotherapy the manifestations of inflammation may be masked.
-early symptoms of inflammation may be malaise or "just not feeling well"
-with infection the temperature may rise, and pulse and resp rate may increase.
vitals signs (fever) moderate fevers
-(up to 103F) usually produce few problems in most pts.
if pts is very young or very old it is extremely uncomfortable
-the use of antipyretics should be considered.
-FEVER w immunosuppressed patient should be treated immediately w antibiotic therapy beca
A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)?
A. Take the antibiotic until the wound feels better.
B. Take the analgesic every day to promote adequate re
answer: C and D
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 sy
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?
A. Increased platele
answer: C
rationale=The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory pr
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?
A. Serous
B. Purulent
C. Fibrinous
D. Catarrhal
answer: B
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
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?
A. Frequent examination of the character and quantity of exudate
B. Monitoring for signs and sympt
answer: C
rationale=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 s
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102�F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication?
A. Pain level
B. Intake and out
answer: B
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 sa
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?
Answer: D
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
A patient with pneumonia has a fever of 103�F. What nursing actions will assist in managing the patient's febrile state?
A. Administer aspirin on a scheduled basis around the clock.
B. Provide acetaminophen every 4 hours to maintain consistent blood level
answer:B
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
Which benign condition shows silver scaly plaques on the skin?
Psoriasis
Hyperpigmented areas that vary in form and color ?
Nevi
Spontaneously occurring raised or irregular-shaped wheals of varying size are usually due to?
Urticaria
A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing inter
answer:
Restlessness with dyspnea
rationale:The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia.
Cloudy drainage may indicate infection, which is not an immediate postoperative complication
Decreased urinary output need
A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress?
Answer:A bland, nonirritating diet is recommended during the acute symptomatic phase.
-During the acute phase, a regular diet can cause discomfort.
-Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea
While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record?
Answer:
Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing
popping, discontinuous sounds caused by air moving into previously deflated airways? what sound is this?
answer: Crackles
is a lower-pitched, coarse, continuous snoring sound that arises from the large airways? what sound is this?
answer: Rhonchus
Which immunomodulatory is beneficial for the treatment of clients with multiple sclerosis?
1.Interleukin 2
2.Interleukin 11
3.Beta interferon
4.Alpha interferon
answer: Beta interferon
Beta interferon is an immunomodulator that is administered in the treatment of multiple sclerosis
After performing an otoscopic examination on a client who reports a decrease in hearing acuity, the primary healthcare provider diagnoses the condition as otitis media. Which assessment finding supports the diagnosis?
answer:redness of the eardrum
Many conditions are associated with a decrease in hearing acuity. One such condition is otitis media. This condition is diagnosed by redness of the eardrum observed during the otoscopic examination.
what are steroids used for?
answer: are used for their antiinflammatory, vasoconstrictive, and antipruritic effects.
-Steroids increase the incidence of infections because they are antiinflammatory agents and mask symptoms of infection.
-Steroids increase fluid retention because the
A client has a history of gastroesophageal reflux disease (GERD). Why should the nurse also monitor the client for clinical manifestations of heart disease?
answer: Esophageal pain may imitate the symptoms of a heart attack.
rationale=Symptoms associated with myocardial infarction may be interpreted by a client as esophageal reflux and therefore ignored.
- Laboratory workups help differentiate these two diagn
Allergic contact dermatitis
is a manifestation of delayed hypersensitivity in which absorbed agents act as antigens.
Sensitization occurs after one or more exposures, and lesions may appear 2 to 7 days after contact with allergens.
Atopic dermatitis
is a genetically influenced, chronic, relapsing disease associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma.
Utricaria
an allergic skin condition that results in a local increase in the permeability of capillaries causing erythema and edema in the upper dermis.
what is osteomylitis?
Osteomyelitis is infection of bone or bone marrow
what is osteomalacia?
Osteomalacia is a condition characterized by softening of bones due to calcium or vitamin D deficiency.
Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells?
answer: Nevi
Rationale=Nevi (moles) are hyperpigmented areas that vary in form and size. Nevi are a common benign condition of the skin that is associated with the grouping of normal cells derived from melanocyte-like precursor cells
what is pneumonia??
Pneumonia is excess fluid in the lungs resulting from an inflammatory process.
what is pharyngitis?
Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis.
what is thermography??
Thermography uses an infrared detector that measures the degree of heat radiating from the skin's surface.
Therefore it is used to investigate the cause of an inflamed joint and in determining the client's response to antiinflammatory drug therapy.
A client is admitted to the hospital with a diagnosis of Crohn disease. What is most important for the nurse to include in the teaching plan for this client?
answer: nutritional needs
rationale=To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished
The consumption of a high-calorie, high-protein diet is advised.
A client is admitted to the hospital with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the client?
answer=hypovolemia
rationale=Hypovolemia that results from a fluid shift from the intravascular compartment to the peritoneal cavity can cause circulatory collapse; this is a life-threatening event that requires immediate intervention
which disease is caused by E coli?
answer= peritonitis
Peritonitis is usually infectious and often life-threatening. It's caused by leakage or a hole in the intestines, such as from a burst appendix.
what bacteria causes food poisoning?
answer=Clostridium botulinum causes food poisoning
A nurse inspects a two-day-old intravenous (IV) site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?
answer= discontinue iv infusion
rationale=The clinical findings indicate the presence of inflammation. The IV catheter should be removed to prevent the development of thrombophlebitis
A client who takes four 325-mg tablets of buffered aspirin four times a day for severe arthritis complains of dizziness and ringing in the ears. Which complication does the nurse conclude that the client probably is experiencing?
answer=Salicylate toxicity
rationale=Excessive aspirin ingestion can influence the vestibulocochlear nerve (cranial nerve VIII), causing tinnitus and dizziness
The client is experiencing symptoms of toxicity
Which laboratory test will be elevated in a client with inflammatory arthritis?
answer=Erythrocyte sedimentation rate (ESR)
rationale=The erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells fall through plasma. This rate is most significantly affected by an increased number of acute-phase reactants, which
A nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease?
answer= Involvement starting distally with rectal bleeding that spreads continuously up the colon
rationale=Ulcerative colitis involvement starts distally with rectal bleeding that spreads continuously up the colon to the cecum. In ulcerative colitis, pat
A client with gastric ulcer disease asks the nurse why the health care provider has prescribed metronidazole. What purpose does the nurse provide?
answer=To treat Helicobacter pylori infection
rationale=Approximately two thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa and interfering with its protective function