Acute inflammation - Answers The immediate response to tissue injury and is short in duration
(minutes to days)
-Swelling
-Pain
-Heat
-Redness
-Loss of function - Answers Localized signs and symptoms of inflammation include:
-Fever
-Leukocytosis
-Malaise
-Fatigue
-Increased pulse & respirations
-Anorexia
-Nausea - Answers Systemic signs and symptoms of inflammation include:
Chronic inflammation - Answers Occurs when inflammation continues for weeks to years after
the initial injury
-CBC with WBC differential
-C-reactive Protein (CRP)
-Erythrocyte Sedimentation Rate (ESR)
-Serological tests to detect specific antibodies or viruses - Answers What are the labs to assess
inflammation?
-Elevated WBC (>11,100 cells/mm^3)
-Elevated neutrophils (>8,000 cells/mm^3)
-Elevated monocytes (>700 cells/mm^3)
-Elevated lymphocytes (>4,000 cells/mm^3) - Answers What are the WBC lab consequences of
inflammation?
,C-reactive protein - Answers A nonspecific protein, produced in the liver, that becomes elevated
during episodes of acute inflammation or infection
Erythrocyte sedimentation rate (ESR) - Answers A nonspecific test for inflammation that
measures how quickly blood cells will settle to the bottom of a test tube; a faster than normal
rate may indicate inflammation in the body
-Age: very young and very old
-Low socioeconomic status
-Geographic location where infection is prevalent
-Immunodeficiency
-Chronic disease
-Environmental conditions: crowded living conditions, absence of clean food/water, insufficient
air ventilation, unsafe sanitary conditions - Answers What factors place a patient at risk for
infection?
-CBC with WBC differential
-Culture & sensitivity
-C-reactive protein (CRP)
-Erythrocyte sedimentation rate (ESR)
-Serological tests to detect specific antibodies or viruses - Answers What are the appropriate
labs to determine the presence of infection?
-Elevated basophils (>100 cells/mm^3)
-Elevated eosinophils (>500 cells/mm^3) - Answers What are the WBC lab consequences of
parasitic infections?
-Elevated WBC (>11,100 cells/mm^3)
-Elevated neutrophils (>8,000 cells/mm^3)
-Elevated monocytes (>700 cells/mm^3)
-Elevated B & T lymphocytes (>4,000 cells/mm^3) - Answers What are the WBC lab
consequences of bacterial or viral infections?
Implementation of pressure injury prevention measures:
-Minimize or eliminate friction & shear (sliding on sheets)
,-Minimize pressure through repositioning, establish turning schedule Q2H
-Pressure-relieving devices
-Assess and manage moisture on skin surfaces
-Maintain adequate nutrition and hydration; offer protein supplements between meals
-Elevate heels off bed - Answers What nursing interventions are necessary for a low Braden
score?
-Intact, non-blistered skin with non-blanchable erythema or persistent redness
-An area that is painful and differs in firmness or temperature from the surrounding tissue -
Answers Criteria for a Stage 1 pressure ulcer include:
-Partial-thickness skin loss with exposed dermis
-Involves the epidermis and/or dermis but does not extend below the level of the dermis
-Shallow and superficial, with a pink wound bed
-Intact or ruptured blisters may be present - Answers Criteria for a Stage 2 pressure ulcer
include:
-Full-thickness skin loss
-Extends into the subcutaneous tissue but does not extend through the fascia to muscle, bone,
or connective tissue
-Undermining and tunneling may be present - Answers Criteria for a Stage 3 pressure ulcer
include:
-Full-thickness skin and tissue loss
-Deeper than stage 3; involves exposure of muscle, bone, or connective tissue
-The considerable depth of the wound and exposure of bone make osteomyelitis likely -
Answers Criteria for a stage 4 pressure ulcer include:
-Obscured full-thickness skin and tissue loss
-The amount of necrotic tissue (eschar) in the wound bed makes it impossible to assess the
depth of the wound or the involvement of underlying structures
-Wound cannot be staged until the necrotic tissue is removed (debrided) - Answers Criteria for
an unstageable wound include:
1.) Four or more ear infections within one year
, 2.) Two or more serious sinus infections within one year
3.) Failure of an infant to gain weight or grow normally
4.) Recurrent, deep skin, or organ abscesses
5.) Persistent oral thrush or fungal infections on the skin
6.) The need for IV antibiotics to clear infections
7.) Two or more deep-seated infections, including septicemia
8.) Two or more pneumonias within one year
9.)Two or more months of antibiotic use with little effect
10.) Family history of PI - Answers The 10 warning signs of primary immunodeficiency include:
Secondary immunodeficiency - Answers A loss of immune functioning (in a person with
previously normal immune function) as a result of an illness or treatment
-Medication in order to avoid rejection of transplanted tissue
-Treatment for various types of cancer - Answers Secondary immunodeficiency may be caused
by:
-Place patient in semi-Fowler's position to optimize lung expansion
-Monitor vital signs
-Perform focused respiratory assessment
-Stay with patient to provide reassurance
-Encourage slow, deep breathing, coughing, and use of an incentive spirometer to aid in airway
clearance
-Administer supplemental oxygen and medication therapies as ordered
-Monitor effectiveness of treatment
-Monitor labs/diagnostics as ordered - Answers Independent nursing interventions for a patient
in respiratory distress include:
-Respiratory rate, rhythm, and depth
-Use of accessory muscles when breathing
-Auscultate lung sounds