Med-Surg Exam #2 - Infection, inflammation, Integumentary

Stage 1 Pressure Injury

Non-blanchable erythema with intact skin; changes in sensation, temperature, or firmness may precede visual changes.

Stage 2 Pressure Injury

Partial thickness loss of skin (exposed dermis); shallow, moist, and open wound with a red-pink wound bed.

Stage 3 Pressure Injury

Full thickness skin loss with subcutaneous and adipose tissue visible; slough may be present.

Stage 4 Pressure Injury

Full thickness skin loss with muscle, bone, tendon exposed; may have slough or eschar.

Unstageable Pressure Injury

Full thickness skin and tissue loss where the extent cannot be determined due to slough and eschar covering.

Deep Tissue Pressure Injury

Localized area of non-blanchable skin with purple or maroon discoloration, intact skin, or blood-filled blister.

Epidemic

An increase in a disease or condition within a certain community or area.

Pandemic

An epidemic that has spread to entire countries or the world.

Localized Infection

An infection limited to a small area of the body.

Emerging Infections

Diseases that have recently increased in occurrence or threaten to come back.

Microbial Resistance

Pathogenic organisms that change and decrease the effectiveness of drugs to treat diseases.

HAI (Healthcare Associated Infections)

Infections acquired due to exposure to microorganisms in a healthcare setting.

Standard Precautions

Precautions used with all patients whenever exposed to blood, body fluids, or non-intact skin.

Inflammation

The body’s response to injury characterized by redness, heat, pain, and swelling.

Nursing Management for Infection Prevention

Assessment of risk factors, education, and management strategies to reduce infection risk.

Primary Intention Healing

Wound healing with edges aligned.

Secondary Intention Healing

Healing occurs from edges with wide, irregular margins; gaping wound edges.

Tertiary Intention Healing

Wound healing occurs after reopening; larger, deeper scar formation.

Signs of Infection

Leukocytosis, increased wound size, odor, drainage, warmth, edema, fever, pain/tenderness.

Nutritional Needs for Healing

Caloric intake of 30-35 cal/kg/day and 1.25-1.5 g protein/kg/day to promote healing.

Clinical Manifestations of Inflammation: Local

Redness, heat, pain, swelling, and loss of function.

Clinical Manifestations of Inflammation: Systemic

Increased WBC, fatigue, nausea, increased HR and RR, fever.

Patient Risk Factors for Infection

Age, autoimmune disease, cancer, diabetes, immunocompromised state, recent surgery, poor hygiene.

Contact precaution

•  gloves, gown; spread via skin-skin contact 

Droplet precaution

mask, gloves, gown; spread from coughing or sneezing

The older adult

• Decreased immune function 

• Have comorbidities 

• Increased physical disabilities 

• Present with atypical S&S: cognitive and behavioral changes before alb values change (confusion), cannot rely on fever to indicate infection (low body temp, decreased immune response), inability to perform ADLs, ask family for baseline  

Benefits of fever (high temps)

• Kills 

• Increases phagocytosis by neutrophils

• Increases proliferation of T cells (lymphocytes) 

• Increases interferon activity 

histamines

causes vasodilation

increases capillary permeability

prostaglandins

vasodilation, pain receptor sensitivity

kinins (bradykinins)

contraction of smooth muscle, pain stimulation

leukotrienes

stimulates chemotaxis