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

Preparation: The Nursing Care of Altered Inflammation

Inflammation is a natural biological response that occurs when tissue injury, trauma, or infection is present. Nurses play a critical role in identifying signs of altered inflammation, supporting the body’s healing process, and preventing complications. Proper assessment, timely interventions, and client education ensure that the inflammatory process contributes to recovery rather than escalating into chronic problems or infection-related complications.

Infection and Inflammation

Which of the following statements about infection and inflammation is accurate?

Option	Accuracy	Explanation
The terms infection and inflammation are interchangeable.	❌ Incorrect	These terms are not synonymous; infection refers to the invasion of pathogens, while inflammation is the body’s response to injury or infection.
Inflammation always accompanies infection.	❌ Incorrect	Not all infections trigger visible inflammation, especially in early or localized stages.
Infection is always associated with inflammation.	✅ Correct	Infection typically results in an inflammatory response as the body attempts to fight pathogens.
Infection and inflammation are not related.	❌ Incorrect	The two are related, but they are distinct processes.

The most accurate answer is “Infection is always associated with inflammation”, as the immune system naturally responds with inflammatory mechanisms when pathogens invade.

Process of Healing

Adam, a 22-year-old student, fractured his wrist and underwent surgical repair with sutures. This exemplifies which type of healing process?

The appropriate answer is primary intention healing. In this process, surgical wounds are closed with sutures, staples, or adhesive strips, leading to minimal scarring and faster healing compared to wounds left to close on their own.

Negative Pressure Wound Therapy

What statement accurately describes negative pressure wound therapy (NPWT)?

The correct statement is:
“Utilization of a vacuum source to facilitate the removal of fluid, exudate, and infectious debris, promoting healing and closure.”

NPWT is widely used for complex wounds, dehisced surgical sites, and ulcers. It enhances perfusion, reduces edema, and encourages granulation tissue formation.

Self-Check: Assessment

When assessing Adam’s surgical incision, which descriptive terms should the nurse incorporate into the assessment note? Select all that apply.

Appropriate terms include: Red and Inflamed.
Purulent or necrotic tissue would indicate complications, while hemorrhagic drainage would suggest uncontrolled bleeding. Nurses should document objective observations to support ongoing evaluation and care planning.

Self-Check: Adam’s Assessment

During Adam’s fall, he sprained his ankle. What is the most appropriate intervention for his soft tissue injury?

The most suitable intervention is applying ice to the ankle for 30 minutes. This helps reduce swelling, inflammation, and pain in the acute phase of injury. Compression and elevation may also be added later as part of the RICE (Rest, Ice, Compression, Elevation) protocol.

Assessments

Before applying compression to Adam’s ankle, which assessments are crucial? Select all that apply.

NR 324 Week 6 Altered Inflammation and Immunity

Assessment	Importance
Distal pulses	Ensures circulation is intact before applying compression.
Capillary refill	Confirms adequate blood flow to distal tissues.
Oral temperature	Less relevant for ankle assessment.
Passive ROM	Useful for mobility but not essential before compression.
Blood pressure	Important in general but not directly related to ankle compression.

The most essential assessments are distal pulses and capillary refill.

The Infectious Process

Which statement made by Adam is the most concerning?

The most alarming statement is: “I don’t know if I can move my fingers or wrist anymore.”

This suggests possible neurovascular compromise, which could be due to compartment syndrome or nerve damage. Immediate intervention is necessary to prevent permanent disability.

Self-Check: Dehiscence Risk Factors

Which factors increase a client’s risk for wound dehiscence? Select all that apply.

Correct factors include: Obesity, Cancer, Diabetes mellitus, and Infection.
Ethnicity does not influence wound dehiscence risk.

Reflection: The Nursing Care of Altered Inflammation

Nurses must continuously assess wound healing and provide education to clients on prevention of complications such as infection, dehiscence, and keloid scarring. Individualized care plans help promote optimal recovery.

Keloid Scarring

Maya, a 24-year-old student, seeks advice about keloid scars. What is the most accurate nursing response?

The correct response is:
“The keloid scars can be removed, but there is a possibility they may recur.”

Keloids are an overgrowth of scar tissue that extend beyond the wound margins. Even after removal, they frequently reappear. Nurses should provide realistic expectations and referral to dermatology if needed.

Dietary Requirements

Adam asks about diet to support healing. Which suggestion is most suitable?

The correct option is: Consume a diet high in protein and high in carbohydrates.

Protein supports tissue repair, while carbohydrates provide energy necessary for metabolic processes during recovery. Vitamins (especially A and C) and minerals like zinc are also vital.

Delegation

Match the appropriate task to the suitable colleague.

This section involves assigning nursing tasks such as monitoring vital signs, assisting with repositioning, or observing for wound changes. Proper delegation ensures safe care delivery while aligning with each team member’s scope of practice.

Hyperthermia

Adam has a fever of 102.6°F. Which interventions are appropriate?

Administering prescribed antipyretics at scheduled times.
Providing tepid sponge baths to promote cooling.
Administering prescribed antibiotics if infection is confirmed.
Avoiding excessive cooling measures such as fans that may cause shivering.