HESI Patient Review: Inflammation, Infection, & Wound Healing - Dave Mason

You question Dave regarding his immunization status. Your initial concern is determining his potential susceptibility to __________ infection. - tetanus Because of the nature of Dave's wounds and their gross contamination with dirt and debris, he is especially susceptible to tetanus infection. Wounds contaminated with dirt may harbor the microorganism, Clostridium tetani. C. tetani thrives in an anerobic environment which is readily provided by deep puncture wounds. A neurotoxin produced by C. tetani can affect nerves and muscles near the wound, and also circulate to other parts of the body, causing generalized muscle spasms. Immunization against tetanus is available. After primary vaccination against tetanus, boosters are indicated every 10 years. For minor, uncontaminated wounds, this provides adequate protection against tetanus. For more serious wounds, a booster is recommended if one was not received within the preceding 5 years. Dave cannot recall when he last received a tetanus 'shot.' Your time with Dave has been brief, but you are able to set priorities for his care. Which of the following is pertinent and most important for Dave's care at this time? - Risk for Infection related to loss of protective skin barrier at injured left thigh Risk for Infection is relevant and Dave's most important problem. His skin, a major defense against invasion of pathogens, is compromised. He is at risk for wound infection, and may be at risk for tetanus infection. In caring for Dave, your primary nursing goal is to: - prevent infection of Dave's wound Risk for Infection is Dave's most important problem. Your primary goal is to prevent Dave's wound from becoming infected. You use Standard Precautions while working with Dave. Standard Precautions are used with Dave because: - Standard Precautions are indicated with all patients Standard Precautions are strategies designed to prevent transmission of infection. They apply to the care of all patients, regardless of diagnosis or infection status. You prepare to care for Dave's wound, by carrying out the most important activity for preventing the transmission of microorganisms, which is: - handwashing The Centers for Disease Control (CDC) identifies hand hygiene (hand decontamination) as the most effective measure against the transmission of microorganisms. Hand hygiene includes handwashing or use of alcohol-based hand rubs. When hands are visibly dirty or contaminated, or known to be contaminated, handwashing is indicated. When soap is used for handwashing, surface contaminants (transient flora) are removed. When hands are washed using antimicrobial agents (may be recommended in high-risk areas, for invasive procedures, with immunocompromised patients, with identified infections), resident flora are removed and pathogens are killed. Hand hygiene is always necessary before procedures that require use of gloves. Hand hygiene is always necessary after procedures requiring use of gloves. Which of the following apply to proper routine handwashing technique? - Hands should be washed for 10-15 seconds Proper handwashing technique requires that hands be washed for a minimum of 10-15 seconds. If hands are visibly soiled, they should be washed for a longer period of time. Friction should be used when hands are washed Friction, but not enough to damage skin, is important for deep cleansing and removal of organisms. Rings should be removed for handwashing If worn, rings should be removed for handwashing. A wristwatch can be pushed above the wrist during handwashing. Some agency policies restrict wearing of rings, because they can harbor microorganisms. You have gathered supplies to clean Dave's wound. Which of the following are indicated for cleansing Dave's wounds? - Gloves should be worn. Gloves should be used when cleansing a wound. Clean gloves are usually sufficient for wound cleansing, unless hand contact with the wound or irrigation fluids/sponges will occur. In this case, sterile gloves would be needed. Gloves reduce the risk of transmission of microorganisms that are present on the hands of the caregiver, to the patient. They also protect caregivers from potential exposure to pathogens. To prevent possible gross contamination of hands with microorganisms and reduce risk of transmission of microorganisms, gloves are indicated when hand contact with blood, body fluids/secretions (except sweat), nonintact skin, or mucous membranes is possible. A face shield and gown should be used A face shield (or mask and eyewear) and gown are recommended for wound cleansing, to prevent splatter into eyes and mouth or onto clothing. Sterile normal saline is appropriate for flushing Dave's wounds because it should: - not damage cells required for tissue repair Normal saline is a non-cytotoxic solution that should not damage or destroy cells needed for would healing. clear away any surface debris Normal saline will remove any gross contaminants, and facilitate examination of the wounds. Which of Dave's wounds has greatest risk for infection? - The puncture wounds The puncture wounds pose the greatest risk for infection. Puncture wounds have wound bases that cannot be visualized, and in which debris can be trapped or hidden. Infectious microbes can lie deep in tissue, where they can grow easily and escape detection. Deep tissue infection can be difficult to treat. Exploration, irrigation, and placement of a drain are sometimes necessary in treating a puncture wound. Your protective clothing is removed when you are done cleaning Dave's wounds. To prevent self-contamination when protective clothing is removed, the clothing is removed in which order? - Remove gloves, remove face shield, undo gown neck, undo gown waist, remove gown This order of clothing removal is best. Removing gloves before the face shield and gown decreases the chance of contaminating the skin or clothing with microbes that might be present on gloves. Protective clothing should be removed before leaving the room. Dave asks about the solution that the physician used to clean his wounds, povidone- iodine (Betadine), and why it's used. Which response is best? - "Betadine is an antiseptic solution that helps to destroy bacteria in a wound." Betadine is an antiseptic with bacteriostatic and bacteriocidal properties. This response to Dave is best. Signs and symptoms of normal inflammation are expected at Dave's wound sites over the next few days. These include: - edema With inflammation and rush of blood to an injured area (secondary to vasodilation), edema is expected. erythema With inflammation and rush of blood to an injured area (secondary to vasodilation), erythema (redness) is expected. tenderness With inflammation and rush of blood to an injured area (secondary to vasodilation), tenderness is expected. Tissue congestion places pressure on nerve endings. warmth With inflammation and rush of blood to an injured area (secondary to vasodilation), warmth is expected. The Td booster Dave receives will provide what kind of immunity? - Artificially-acquired active immunity Artificially-acquired active immunity occurs when a person receives a killed or live attenuated microbe or a modified microbial toxin. The introduction of the microbial substance causes the individual to produce antibodies against the microbe, so that disease will not occur. When Dave receives the Td booster, it will include small amounts of tetanus and diphtheria toxins (antigens), enough to stimulate his immune system to produce antibodies to fight the respective toxins. This will provide active immunity. Passive immunity is provided when a person receives antibodies, such as TIG (tetanus immune globulin). If completion of primary immunization against tetanus was uncertain in Dave's case, passive immunization against tetanus would also have been indicated. Which of the following instructions are appropriate for Dave? - Wash hands before caring for wounds Washing hands before caring for wounds will decrease the likelihood of introducing microbes into the wounds. Wash hands after caring for wounds Handwashing after caring for wounds will decrease risk of transmission of any organisms to other body areas or other persons. Gently cleanse away any debris Wound cleansing of any debris is indicated. Contaminants could cause infection. Debris can interfere with wound healing. Scabs can also interfere with wound healing. You teach Dave that he can make his own wound-cleansing solution at home. A possibility is: - mixing 2 teaspoons of salt in 4 cups of boiled tap water This solution would be a sterile, normal saline solution that would be safe and effective for wound cleansing once it has cooled below 100 degrees F. for wound care, as per usual wound care guidelines. When leaving the room, after glove removal, contact with surfaces in the room should be avoided. A clean gown is required when clothing may come in contact with Dave or any of his body secretions When Contact Precautions are in effect, a clean gown is required when contact with Dave, any body secretions, or any surfaces or personal items in his room is expected. When leaving the room, after gown removal, contact with surfaces in the room should be avoided. You know that acetaminophen should be effective in reducing Dave's temperature because of its ____________ action. - antipyretic Acetaminophen has an antipyretic action that should help to lower Dave's body temperature. With infection, the body's "thermostat" is reset at a higher level. Heat- producing activities (vasoconstriction and shivering) occur to reach the higher "thermostat" level. Once the level is reached, heat-reducing activities (vasodilation and sweating) are initiated, to maintain body temperature at the "thermostat" setting. Antipyretic drug effects reset the body's "thermostat" to its normal level. Temperature should decrease. Dave has many friends, and flowers and potted plants are at his bedside. One of the flower arrangements needs water. Which of the following is preferable? - Ask a staff person who does not provide patient care to take care of adding water to the flower arrangement This infection control practice is recommended by the Centers for Disease Control (CDC) as preferred when flowers or plants in patient care areas must be cared for. If flower or plant care by patient-care staff cannot be avoided, the person should use gloves and perform hand hygiene afterwards.