NR 324 Week 6 Altered Inflammation and Immunity

NR 324 Week 6 Altered Inflammation and Immunity

Student Name

Chamberlain University

NR-324 Adult Health I

Prof. Name:

Date

Altered Inflammation and Immunity Nursing Care

Altered Inflammation

Inflammation is a complex biological response to harmful stimuli such as pathogens, damaged cells, or irritants. It is a protective mechanism aimed at removing injurious stimuli and initiating the healing process. Nursing care for patients experiencing altered inflammation involves assessment, timely interventions, and patient education to support recovery and prevent complications.

Preparation: The Nursing Care of Altered Inflammation

Inflammation and infection are distinct yet interconnected processes. A common misconception is that they are interchangeable. While inflammation often accompanies infection, it can also occur independently in conditions like autoimmune diseases or physical trauma. Therefore, the accurate understanding is:

Process of Healing

Adam, a 22-year-old skateboarding enthusiast, underwent surgery to repair a wrist fracture. His sutured surgical wound illustrates primary intention healing, where wound edges are clean and closed promptly, minimizing scarring and recovery time.

Negative Pressure Wound Therapy

Negative Pressure Wound Therapy (NPWT) supports wound healing by applying localized negative pressure to draw out fluids and infectious materials. It is best described as:

“The use of a vacuum system to extract fluid, exudate, and debris, thus promoting healing and wound closure.”

Self-Check: Assessment

When evaluating Adam’s incision, nurses should accurately describe the wound’s appearance. Appropriate terms include:

Self-Check: Adam’s Assessment

Adam’s sprained ankle should be managed using compression with an elastic bandage, which helps reduce swelling and stabilize the injury.

Assessments

Before applying compression, nurses should complete the following evaluations:

The Infectious Process

Of Adam’s reported symptoms, the statement of highest concern is:

“I don’t know if I can move my fingers or wrist anymore.”

This may indicate neurovascular compromise requiring immediate attention.

Self-Check: Dehiscence Risk Factors

Wound dehiscence can result from several factors. High-risk conditions include:

Reflection: The Nursing Care of Altered Inflammation

Keloid Scarring

When Maya inquires about keloid scar treatment, the nurse should respond accurately and supportively:

“Keloid scars can be treated, but there is a risk of recurrence even after removal.”

Dietary Requirements

Adam should be advised to:

“Consume a diet high in protein and carbohydrates,” which promotes tissue repair and energy for recovery.

Delegation

Appropriate delegation involves assigning specific tasks to appropriate personnel based on scope of practice. For instance:

Hyperthermia

Adam’s fever should be managed through:

• Consistent administration of antipyretics
• Tepid sponge baths
• Administration of antibiotics if prescribed

Placing a fan can be supportive, but pharmacological and therapeutic interventions are primary.

Classifications

Negative Pressure Wound Therapy

When managing NPWT, nurses must:

Outcomes and Goals

The following outcomes support the diagnosis of impaired tissue integrity:

• Adam reports changes in sensation or pain.
• Adam understands and follows his care plan.
• Adam gradually increases activity to improve circulation.

Full healing before discharge may not always be realistic.

Wound Dressings

While dressing Adam’s wound, a student nurse’s statement such as:

“How do you handle that unpleasant smell?” requires correction, as it may reflect unprofessionalism.

Pressure Ulcers

Preparation: Pressure Ulcers

Pressure Ulcer Risk Factors

Common contributing factors include:

Ulcer Classifications

A stage II pressure ulcer involves:

“Partial thickness skin loss with a red-pink wound bed and no slough.”

Common Locations for Pressure Ulcers

Areas prone to pressure ulcers include:

Self-Check: Nursing Actions – Pressure Ulcer Prevention

Effective strategies for Jan include:

• Repositioning every two hours

NPO status and bedrest are inappropriate without specific indications.

Self-Check: Suspected Deep Tissue Injury

To assess suspected deep tissue injury in clients with darker skin tones:

“Assess for changes in temperature or consistency in the area.”

Self-Check: Wound Descriptions

Best description:

“Oval-shaped, pink moist wound bed, approx. 6 cm x 4 cm, undermining from 12 to 1 o’clock.”

Self-Check: Delayed Wound Healing

Factors delaying healing include:

The nurse should intervene if a student visibly shows disgust, as it affects patient dignity and professional standards.

Reflection: Pressure Ulcers

Ulcer Stages

Braden Scale

Based on Jan’s presentation:

References

American Academy of Family Physicians. (2022). Wound care: Negative pressure wound therapy. https://www.aafp.org/pubs/afp/issues/2022/0201/p168.html

Australian Nursing and Midwifery Journal. (2021). Evidence-based practice in wound care. https://anmj.org.au/evidence-based-practice-in-wound-care/

Centers for Disease Control and Prevention. (2020). Guidelines for preventing health-care-associated infections. https://www.cdc.gov/infectioncontrol/guidelines/index.html

NR 324 Week 6 Altered Inflammation and Immunity

National Institute for Health and Care Excellence. (2019). Pressure ulcers: Prevention and management. https://www.nice.org.uk/guidance/ng89

World Health Organization. (2021). Infection prevention and control. https://www.who.int/health-topics/infection-prevention-and-control