HESI Patient Review: Inflammation, Infection, & Wound Healing - Dave
Mason
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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.
You question Dave regarding his immunization status. Your initial
A neurotoxin produced by C. tetani can affect nerves and muscles
concern is determining his potential susceptibility to __________
near the wound, and also circulate to other parts of the body, causinfection.
ing 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.'
Risk for Infection related to loss of protective skin barrier at injured
left thigh
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 Risk for Infection is relevant and Dave's most important problem.
important for Dave's care at this time?
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.
prevent infection of Dave's wound
In caring for Dave, your primary nursing goal is to:
Risk for Infection is Dave's most important problem. Your primary
goal is to prevent Dave's wound from becoming infected.
Standard Precautions are indicated with all patients
You use Standard Precautions while working with Dave. Standard
Standard Precautions are strategies designed to prevent transPrecautions are used with Dave because:
mission of infection. They apply to the care of all patients, regardless of diagnosis or infection status.
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
You prepare to care for Dave's wound, by carrying out the most visibly dirty or contaminated, or known to be contaminated, handimportant activity for preventing the transmission of microorgan- washing is indicated. When soap is used for handwashing, surisms, which is:
face 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.
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.
Which of the following apply to proper routine handwashing techFriction should be used when hands are washed
nique?
Friction, but not enough to damage skin, is important for deep
cleansing and removal of organisms.
Rings should be removed for handwashing
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HESI Patient Review: Inflammation, Infection, & Wound Healing - Dave
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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.
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
You have gathered supplies to clean Dave's wound. Which of the
of hands with microorganisms and reduce risk of transmission
following are indicated for cleansing Dave's wounds?
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.
not damage cells required for tissue repair
Sterile normal saline is appropriate for flushing Dave's wounds
because it should:
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.
The puncture wounds
Which of Dave's wounds has greatest risk for infection?
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.
Remove gloves, remove face shield, undo gown neck, undo gown
waist, remove gown
Your protective clothing is removed when you are done cleaning
Dave's wounds. To prevent self-contamination when protective
This order of clothing removal is best. Removing gloves before the
clothing is removed, the clothing is removed in which order?
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.
"Betadine is an antiseptic solution that helps to destroy bacteria in
Dave asks about the solution that the physician used to clean
a wound."
his wounds, povidone-iodine (Betadine), and why it's used. Which
response is best?
Betadine is an antiseptic with bacteriostatic and bacteriocidal
properties. This response to Dave is best.
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HESI Patient Review: Inflammation, Infection, & Wound Healing - Dave
Mason
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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.
Signs and symptoms of normal inflammation are expected at
Dave's wound sites over the next few days. These include:
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.
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
The Td booster Dave receives will provide what kind of immunity?
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.
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
Which of the following instructions are appropriate for Dave?
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.
mixing 2 teaspoons of salt in 4 cups of boiled tap water
You teach Dave that he can make his own wound-cleansing soThis solution would be a sterile, normal saline solution that would
lution at home. A possibility is:
be safe and effective for wound cleansing once it has cooled below
100 degrees F.
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HESI Patient Review: Inflammation, Infection, & Wound Healing - Dave
Mason
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A dry cold compress placed over the dressed wound area for today
Vasodilation associated with inflammation increases blood flow
to an injured area. During the first 24 hours after tissue injury, a
cold application helps to prevent excessive edema and pain. Cold
causes vasoconstriction. After 24 hours, the application of heat
causes vasodilation and facilitates removal of debris and excess
fluid from an injured area.
Acetaminophen by mouth every four hours as needed
Dave asks what he can do to alleviate the throbbing pain he feels
Although it does not have an antiinflammatory effect, acetaat the wound site. Which of the following should help?
minophen blocks pain impulses and alleviates mild to moderate
pain. It should help alleviate Dave's discomfort. The physician has
recommended its use.
Leg elevation
Vasodilation associated with inflammation increases blood flow to
an injured area. Subsequent edema can contribute to pain. Leg
elevation promotes venous return and can help avoid excessive
edema and pain. Dave's leg should also be rested. Activity would
increase blood flow to the injured areas and cause discomfort.
increasing redness and swelling at a wound site
With onset of infection, redness and swelling would increase and
persist at a wound site.
green or yellow drainage from a wound site
Dave is also taught about signs and symptoms of infection to
watch for and report. These include:
Some serous drainage may occur with normal inflammation. However, yellow or green drainage should be reported as these generally indicate infection.
odor coming from a wound site
Odor coming from a wound site almost always indicates infection,
and should be reported.
an elevated body temperature
It is not unusual for a wound infection to cause a systemic temperature elevation. Onset of fever should be reported. Often, temperature over 38.4 degrees C (101.1 degrees F) is reported.
Have Dave demonstrate the dressing technique he will use
To evaluate the effectiveness of your teaching with Dave, which of
Return demonstration is the best indicator of ability to perform a
the following would be best?
psychomotor skill such as a dressing change. Dave can demonstrate dressing technique on his non-injured thigh.
Three patients with medical conditions (peptic ulcer disease, diverticulitis, back pain)
Unfortunately, an isolation room is not available for Dave. He will
need to be in a 4-bed room. Of the patient mix below, which is best This is the best choice of roommates for Dave. None of these
for Dave?
patients has had or is currently expected to have surgical intervention, which would place them at risk for infection from Dave's
microbes. Also, these three patients pose no special risk for Dave.
Take the wound and blood cultures
Cultures should be taken before antibiotic therapy is started.
Antibiotics can interfere with microbial growth in the laboratory.
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HESI Patient Review: Inflammation, Infection, & Wound Healing - Dave
Mason
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After reviewing Dave's orders, which of the following should you
implement first?
Microbial identification is important in determining appropriate
antibiotic therapy. In the meantime, a broad-spectrum antibiotic
has been ordered. Wound cultures are ordered to identify the
infecting organism(s) in Dave's wound.
Thoroughly rinse wound with sterile saline prior to culturing
Thoroughly rinsing a wound with sterile saline prior to culturing should eliminate normal skin flora from culture specimens.
Cleaning the wound with an antimicrobial agent such as hydrogen
peroxide should not be done, as this could eliminate pathogens
that need to be identified.
Of the techniques shown below, which are appropriate when
culturing Dave's left thigh wound?
Rotate culture swab within the wound from edge to edge
Rotating a culture swab from wound edge to wound edge allows
for coverage of a entire wound bed and increases the likelihood
that any organisms present are obtained. Care should be taken to
avoid the actual wound edge. Sterile Ca Alginate or rayon swabs
should be used (NOT COTTON). A culture may also be obtained
by needle aspiration. Agency protocols should be followed.
Draw the specimens from two venipuncture sites separate from
the IV site
After culturing Dave's wound, you proceed to take the blood
When blood cultures are ordered, specimens should be taken from
cultures that are ordered. Which of the following describes correct two separate venipuncture sites. Any established IV access site
technique?
should not be used. Blood culture specimens drawn through an IV
site would probably be contaminated with organisms that might be
present at the catheter site, and not those originating from Dave's
wound.
wear gloves
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. This approach is part of Standard Precautions.
cleanse the venipuncture sites with an antiseptic
When taking the blood cultures, you correctly:
When blood cultures are drawn, an antiseptic solution should
be used to cleanse the venipuncture sites. This helps prevent
contamination of the blood specimen with microbes from the skin.
Povidone-iodine (Betadine) or 70% alcohol may be used. Agency
policy should be followed.
cleanse the tops of the culture tubes/bottles with an antiseptic
When blood cultures are drawn, an antiseptic solution should
be used to cleanse the tops of culture tubes/bottles. This helps
prevent contamination of the blood specimen with microbes from
the tubes/bottles. Povidone-iodine (Betadine) or 70% alcohol may
be used. Agency policy should be followed.
nosocomial
A hospital-acquired infection is also called a/an ___________
infection.
An infection acquired as a result of hospitalization is called a nosocomial infection. Generally, infections that develop 48 hours after
admission are considered hospital-acquired. The most common
nosocomial infections are urinary tract infection, surgical wound
infection, pneumonia, and bacteremia (usually associated with
intravascular access devices).
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HESI Patient Review: Inflammation, Infection, & Wound Healing - Dave
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Wear gloves and clarify proper procedure for next time
Which of the following approaches is BEST if you are in doubt as
to whether or not gloves should be worn for patient contact?
Wearing gloves when uncertain is the safest approach to ensure
self-protection and protection of the patient and others.
Obtain and set up a new sterile field with new sterile supplies
You proceed with Dave's wound care using surgical asepsis. You
set up a sterile field, placing all required sterile supplies on the
In surgical asepsis, a wet field is considered contaminated unless
field. Inadvertently, some sterile saline moistens the center of the the surface on which it rests is sterile. When moisture penetrates a
sterile field. What should you do?
sterile barrier, capillary action allows bacteria on the surface below
to migrate onto the field.
absorb exudate
Gauze will absorb excess wound drainage, yet maintain an adequately moist environment, supportive of wound healing.
accomplish debridement
If applied and kept moist, the all-cotton gauze will accomplish
autolytic debridement. Autolytic debridement allows the body's
own fluids to soften and loosen the bonds that hold any necrotic
tissue in a wound bed and absorb any tissue debris that occurs
with wound healing. It is important that cotton gauze be used.
After irrigating Dave's wound, you proceed with loosely packing
Use of a synthetic sponge product could cause wound desiccation
the laceration with saline-moist 100% cotton gauze. The moist
(drying up) within 48 hours.
saline gauze is intended to:
fill dead space in the wound
Dead space in a wound must be obliterated to permit wound
healing. Loosely packing a wound with gauze will eliminate dead
space.
maintain a moist wound bed
A moist wound environment facilitates wound healing. If applied
and kept moist, gauze will maintain an adequately moist wound
healing environment.
Contact
CDC guidelines include Standard Precautions and Transmission-Based Precautions. Transmission-Based Precautions apply
when a person is known to be infected (or colonized) or suspected
According to guidelines established by the Centers for Disease
of infection (or colonization) with transmissible pathogens. Contact
Control (CDC), in addition to Standard Precautions, what precauPrecautions are for patients known or suspected to have illness
tions should be followed for Dave?
transmitted by direct contact with the patient or indirect contact
with surfaces or personal items in the patient's environment. According to CDC guidelines, Contact Precautions are indicated
when cellulitis with drainage is present, until the wound stops
draining.
Gloves should be used while providing direct care
When Contact Precautions are in effect, gloves are indicated for
routine care and wound care. For routine care, clean gloves are
adequate. Sterile gloves should be used for wound care, as per
Which of the following isolation protocols are indicated for Dave's usual wound care guidelines. When leaving the room, after glove
care?
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
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HESI Patient Review: Inflammation, Infection, & Wound Healing - Dave
Mason
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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.
antipyretic
You know that acetaminophen should be effective in reducing
Dave's temperature because of its ____________ action.
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.
Ask a staff person who does not provide patient care to take care
of adding water to the flower arrangement
Dave has many friends, and flowers and potted plants are at his
This infection control practice is recommended by the Centers
bedside. One of the flower arrangements needs water. Which of
for Disease Control (CDC) as preferred when flowers or plants
the following is preferable?
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.
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