Nurse's Guide to Infection, Inflammation, and Wound Management

What findings are concerning: Confusion and lethargy. Confusion and lethargy were not assessed upon admission yesterday at 1200. A new assessment of confusion and lethargy 24 hours later would need immediate follow-up. Laboratory results. The laboratory results show an elevated WBC count, which indicates a possible infection and would require follow-up. Vital signs. Vital signs indicate the client has an elevated temperature and heart rate, which may indicate an infection and require follow-up. What could be happening: Infection or Osteomyelitis: Delirium in older adults, fever, elevated WBC, pain, swelling, warmth to affected area. What is the nurse’s priority action: Administer Vancomycin IV, Surgical debridement, Wound care per provider orders, hyperbaric oxygen therapy. What education should the nurse provide: Turn client at least every 2 hours. Apply barrier cream after incontinence. Barrier cream would be applied to prevent further skin breakdown caused by moisture after ensuring client is clean and dry. Encourage high protein diet. A high-protein diet will assist in wound healing. Encourage ambulation or range of motion in bed. Early ambulation or range of motion exercises are encouraged to promote mobility and prevent pressure injuries. Utilize evidence-based tools to prevent pressure injuries. Evidence-based measures such as frequent turning reminder tools, Braden scale, and specialty mattresses are implemented to prevent pressure injuries. The body’s inflammatory response is a reaction of the cell to injury. The primary focus of this response is to neutralize and minimize the effect of the injury so that healing and repair can happen. Acute: Neutrophils are the main cell type at the site of inflammation.? Healing occurs in 2–3 weeks.? No residual damage occurs.? Example: swelling at the site of a vaccine injection Subacute: Falls between acute and chronic, lasting 2–6 weeks? Example: infectious endocarditis Chronic: Lymphocytes and macrophages are the main cells at the site of inflammation.? Chronic inflammation can last weeks, months, or years.? Residual damage occurs due to the frequency of inflammation or injury.? Examples: rheumatoid arthritis, chronic inflammatory response syndrome (CIRS), obesity, allergies Whether occurring deep in the body (e.g., pyelonephritis) or on the surface (e.g., the palm of hands scraped during a fall), the clinical manifestations of inflammation are the same:? heat (localized warmth or systemic fever)? redness? swelling? pain? eventual loss of function ? Some of these responses can be beneficial in wound healing and infection control or pathological, as in many chronic disease states. Diseases in which inflammation plays a dominant pathological role have the suffix "-itis," such as appendicitis. The specific immune cells and mediators vary by type, onset, and duration of the injury. However, high-specificity C-reactive protein (hs-CRP) levels are widely used to diagnose bacterial (not viral) infections and inflammatory disorders. A positive hs-CRP test indicates inflammation is present but not what caused the inflammatory response. CRP levels tend to be higher in older adults and people with conditions that cause acute or chronic inflammation, such as cancer and obesity.? The normal value of hs-CRP is < 1.0 mg/dL Inflammation vs. Infection: The left image represents that inflammation is always present with infection. The right image represents that inflammation can also occur without an infection being present. Nursing care: (Prevention) Eat a healthy diet.? Exercise regularly.? Take routine medical and dental care.? Avoid injury when possible.? Wear protective equipment during high-risk activities. Acute care: Fever? Fever is associated with infection but should not be treated if low to moderate (up to 103 °F [39.4 °C]) as it is part of the immune response. ? Non-steroidal anti-inflammatory drugs (NSAID; e.g., aspirin and ibuprofen) and acetaminophen are used to lower fever, if needed.? Older adults and clients who are immunocompromised may not experience fever with inflammation, so other indicators should be assessed.? Soft tissue injuries (e.g., sprains and strains) are treated using the acronym RICE (rest, ice, compression, and elevation). ? Reddened skin indicates altered blood flow to the injured area. To avoid injuring the tissue, do not massage reddened skin. RICE Rest Ice Compression Wounds/ Exudate Elevation Exudate: Serous?: Seen in the early stages of inflammation or when an injury is mild; watery looking fluid/discharge?. Serosanguineous: Composed of red blood cells and serous fluid, which gives it a semi-clear pink color and may have red streaks.? Hemorrhagic?: Frank blood; results from rupture or necrosis of blood vessel walls?. ?Purulent (pus): Sign of infection; may have an odor; consists of debris (both dead and alive microorganisms), liquefied dead cells, and white blood cells; can be yellowish-green/gray in color.? If an individual goes to the emergency department and has sutures placed, the injury will heal and result in a fine scar. This is primary intention healing. If an individual leaves the injury alone and decides not to seek treatment, the body will create a blood clot to help heal itself. Granulation tissue will form on the bottom of the wound bed and heal itself from the inside out until the wound is filled in. The client may have a larger scar from this healing process. This is secondary intention healing. The person forgets the injury is there and the wound becomes infected. (What type of exudate is likely to be present?) They then seek treatment and the infection is treated. Granulation tissue will form, just as in secondary intention healing, but then the wound is sutured closed to prevent further infection. This is tertiary intention healing and commonly results in a scar that is larger and deeper than primary or secondary intention. Hypertrophic scarring comes from an overabundance of connective tissue and collagen trying to repair the wound bed. This scar is raised but stays within the borders of the injury. Over time, hypertrophic scars will recede. Keloid scars are an overproduction of collagen and scar tissue that extends beyond the edges of the wound. This is a permanent scar, with a chance of recurrence with all injuries. This occurs most often with dark-skinned clients, particularly African Americans. Dehiscence is the separation and disruption of previously joined wound edges. In this example, the suture line from the client’s injury has separated. This is commonly paired with the concept of evisceration, or when the wound edges separate so much that organs actually protrude through the wound itself. Debridement: Surgical debridement is a surgical procedure that can be done in an office, treatment center, or surgical suite. The procedure is a quick way to clean the wound bed by removing large foreign objects (e.g., gravel or splinters), nonviable tissue, or infected tissue to leave a clean wound bed for natural healing.? Mechanical debridement is used to remove contamination over time and can be done in several ways. ? Wet-to-dry dressings use sterile dressing material soaked in a sterile liquid (such as normal saline), placed into the wound, and allowed to dry. When the dry dressing is removed, the contamination is removed. ? Wound irrigation uses a sterile liquid (such as normal saline) or solution (e.g., Dakin’s solution or antibiotic solution) to wash contaminants from the wound bed.? Compression drains, such as a Jackson-Pratt (JP) drain, are low-tech means to apply negative pressure. Using a compressible bulb connected to the wound by tubing, the JP drain is placed in the wound during a surgical procedure. The bulb should remain compressed and be emptied as needed. After emptying, compress the bulb before closing the drainage port. The bulb should always remain compressed to be effective. Negative pressure wound therapy (NPWT), often called a “wound vac,” creates continuous or intermittent negative pressure inside the wound bed to remove fluid, exudate, and infectious debris so the wound can heal and close. The negative pressure also increases blood flow to the wound bed, increasing the nutrients and oxygen needed for healing.? With this intervention, thick foam is cut to the size of the wound. Next, it is inserted into the wound bed and a sizeable occlusive dressing is placed tightly over it. Next, a small opening is made in the occlusive dressing to attach the drainage tubing to the vacuum pump. Once turned on, the pump creates negative pressure in the wound bed, causing the foam and occlusive dressing to shrink—like vacuum-sealed food. It is imperative that the occlusive dressing is sealed on all sides. If the dressing is not occlusive, the vacuum pump of the NPWT cannot create appropriate negative pressure in the wound, rendering the therapy useless. In addition, it is essential to monitor the client’s protein levels and electrolyte and fluid balance due to the potential loss from the wound. Nutrients for Healing? Water loss occurs through perspiration, exudate formation, and increased metabolism rate, so care must be taken to maintain optimal hydration. If the client is unable to maintain hydration and nutrition through oral intake, enteral or parenteral options should be considered.? A diet high in protein, carbohydrates, and vitamins is needed to promote wound healing. ? Protein offsets the negative nitrogen balance resulting from increased metabolic rate and the synthesis of immune factors, blood cells, fibroblasts, and the collagen used for healing.? Carbohydrates provide energy in the form of simple sugars, allowing the body to use protein for healing, rather than as an energy source.? Vitamin C is used for capillary synthesis and the production of collagen by fibroblasts.? B-complex vitamins serve as co-enzymes for metabolism. If deficient, healing is delayed.? Vitamin A supports epithelization and increases the strength of the healing wound. Risk factors for pressure ulcer development include: ? obesity? immobility? advanced age? incontinence? impaired circulation ? contractures ? neurologic disorders/deficits The Braden Scale (ON NEXT SLIDE), published in 1987, gives healthcare providers a snapshot of the amount of risk a client has in developing pressure or skin integrity issues. The scoring ranges from less than 9 to a high of 23. The lower the number, the higher the risk of developing an acquired ulcer or skin integrity injury. 19-23 = no risk? 15-18 = mild risk? 13-14 = moderate risk?? 10-12 = high risk less than 9 = severe risk Six categories are evaluated within the Braden Scale: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Nurses should complete a Braden Scale assessment on all clients at least once a shift, and upon admission. The key to positive outcomes for clients is prevention. The Braden Scale will help healthcare providers anticipate what risk the client has and how to best prevent it in a proactive manner. Stage 1: non-blanchable erythema. Usually found over bony prominences such as the coccyx, heels, and elbows. Client may report pain. Stage 2: Partial thickness shallow, open ulcer. Reddish-pink wound bed. May also be blisters (intact or ruptured) that weep serosanguinous fluid. Stage 3: Full-thickness wound. No bone, tendon, or muscle is exposed, but subcutaneous fat may be. Tunneling and undermining may begin to form. Stage 4: Wound with exposed bone, tendons, or muscle. Slough or eschar may be present. Undermining and tunneling are commonly found. Unstageable: Slough or eschar obscures the view of the wound. Staging can be done after slough or eschar are removed. Suspected deep tissue injury: Purple or maroon discolorations on intact skin or what appears to be blood-filled blisters. Damage from pressure or shearing forces. Removing Old Dressing Carefully remove the old dressing and packing, if used, without pulling on the skin?. Assess and document (with pictures, if required by the facility)? peri-wound area, granulation tissue, eschar, slough? wound dimensions with wound measuring guide (length, width, depth)? undermining/tunneling with a sterile cotton-tipped applicator? Remove and dispose of gloves?. Perform hand hygiene?. Cleaning and Dressing the Wound Open supplies maintaining sterile technique and prepare sterile field (as appropriate)?. Don PPE (gown, mask, and protective eye wear or face shield)?. Don sterile gloves and prepare a sterile field?. Establish which hand will remain sterile throughout the procedure?. Draw up sterile solution with a 60 ml syringe and obtain approximately three to four gauze pads from the sterile field?. Clean and irrigate the wound using gauze pads to catch solution and debris. Begin irrigation, starting at the top of the wound. Continue to irrigate until the solution flowing out of the wound is clear?. Pat peri-wound area with gauze pads as needed to dry. Do not reuse the same gauze pad?. Discard gauze into an appropriate receptacle?. Using a cotton-tipped applicator, gently pack the wound with gauze dressing moistened with sterile saline?. Apply dry gauze over the wound to cover wound packing?. Apply appropriate absorbent dressing over dry gauze and secure with tape?. Dispose of supplies into an appropriate receptacle?. Remove and discard gloves and PPE into a trash receptacle. Perform hand hygiene?. Label the dressing with initials, date, and time?. Assess COCA: color odor consistency amount Nursing Management: Turn and reposition the client at least every 2 hours. This gives the skin time to breathe and a break from the body weight and pressure applied to it. If areas of non-blanchable erythema are present, reassess in 20 minutes. If the erythema remains, the client should be repositioned more frequently. Do not rub reddened areas, simply make sure all pressure is off them until the skin returns to baseline.? Prevent excessive moisture buildup. This may include helping the client find an appropriate temperature for their room, administering ordered antipyretics for fever and sweating, or changing the client’s linens to those that are not moist. This lack of moisture will decrease the risk for skin breakdown. Increase the client’s protein intake! This will increase the amount of amino acids available for the body to use in tissue regeneration and repair. Provide more oxygen to the body, whether that be through supplemental oxygen or blood transfusions for the anemic client. The lack of oxygen that occurs in anemia leaves less oxygen available in the tissues for nutrients. Place the client on a pressure relieving mattress to help redistribute body weight and decrease shearing force and pressure. Remember: This does not take the place of repositioning and turning clients. This is just an additional intervention to assist in relieving pressure. The Braden Scale (ON NEXT SLIDE), published in 1987, gives healthcare providers a snapshot of the amount of risk a client has in developing pressure or skin integrity issues. The scoring ranges from less than 9 to a high of 23. The lower the number, the higher the risk of developing an acquired ulcer or skin integrity injury. 19-23 = no risk? 15-18 = mild risk? 13-14 = moderate risk?? 10-12 = high risk less than 9 = severe risk Six categories are evaluated within the Braden Scale: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Nurses should complete a Braden Scale assessment on all clients at least once a shift, and upon admission. The key to positive outcomes for clients is prevention. The Braden Scale will help healthcare providers anticipate what risk the client has and how to best prevent it in a proactive manner. Immunity is described as the protection from illness or disease that is maintained by the body’s physiologic defense mechanisms. The body’s immune response serves three functions:? Protection against invasions by microorganisms and prevention of infection by attacking foreign antigens and pathogens. ? Digestion and removal of damaged cellular substances, thereby maintaining homeostasis. ? Surveillance and destruction of foreign cells. ? Innate (or natural) immunity is present at birth. This type of immunity provides a nonspecific response against pathogens. Neutrophils and monocytes are the primary white blood cells involved. Innate immunity is not antigen-specific. Therefore, it can respond quickly to an invading microorganism without prior exposure to that organism. Acquired immunity is developed either actively or passively. Active acquired immunity results from the invasion of the body by foreign substances, such as microorganisms, and the subsequent development of antibodies and sensitized lymphocytes. This type of immunity develops naturally from a disease, such as chickenpox, or artificially through immunization. ? Passive acquired immunity results when an individual receives antibodies to an antigen rather than making them. This can occur naturally through the transfer of immunoglobins from mother to baby across the placenta or through colostrum or passively through injection with gamma globulin (serum antibodies). Immunoglobulins, also called antibodies, are glycoprotein molecules produced by plasma cells (white blood cells). They are a critical part of the immune response by specifically recognizing and binding to specific antigens and aiding in their destruction. If immunoglobulins are deficient, infections occur. IgG This antibody is commonly found in the blood and bodily fluids. IgG establishes and remembers a pathogen in the future after first exposure. IgG crosses the placental membrane and provides the newborn with passive immunity for about 3 months after birth. IgA This antibody can be found in the lining of the respiratory and digestive tracts. IgA regulates immune function in the mucous membranes. IgA is found in colostrum and breastmilk. IgM This antibody is commonly found in the blood and in the lymph. IgM is created to fight a current pathogen. IgD This antibody can be found in the blood, but in small amounts. IgD activates basophils, mast cells, and B cells that are part of the inflammatory and immune response. IgE This antibody can be found in the blood, but in small amounts. IgE can increase if a foreign body or microorganism is present. IgE drives an allergy reaction when sensing an allergen. Nursing Care: Altered Immune Response Risk factors for altered immune response include:? aging? lack of immunization? chronic illness that weakens the immune system? chronic drug therapy, such as corticosteroids and chemotherapy? substance use disorder? lack of healthy lifestyle? genetic risk for decreased or excessive immunity Wash your hands often using soap and water. Dry your hands completely after washing. Bathing daily lowers the number of microorganisms on the skin, thereby decreasing the risk of infection. Use an electric razor when shaving to prevent cuts where microorganisms can enter the body. Brush your teeth twice every day to minimize infections in the mouth. Prevent constipation by increasing fluids. Constipation can cause a tear in the rectum, leading to infection. Stool softeners may be necessary. Avoid the use of tampons, which can cause vaginal tears leading to infection. Avoid sharing personal items with others, especially drinking glasses, eating utensils, and bath towels.? Avoid fresh flowers, live plants, and standing water as microorganisms can grow in soil and water. Avoid contact with animal feces, urine, and saliva which may lead to infection. Avoid eating raw, unwashed fruits and vegetables. Raw or undercooked eggs and soft cheeses with mold should be avoided as well. Do not eat undercooked meats. Use a food thermometer to ensure food is cooked to the correct temperature. Avoid large crowds and anyone with a communicable disease. Place the client in a single-patient room with a private bathroom. ? Avoid nurse assignments that include an infectious client and an immunocompromised client.? Use a client room with directed positive pressure air flow that is well-sealed to prevent air from the outside.? Implement strategies to minimize dust, including routine cleaning.? Prohibit dried or fresh flowers and potted plants in the client’s room. ? If dust-generating activities are ongoing in a healthcare facility (e.g., construction, renovation), then the client should wear a N95 mask when leaving the room. ? Nurses should follow standard or transmission-based precautions (as indicated) in the care of immunocompromised clients (Centers for Disease Control and Prevention, 2022). Contact dermatitis is caused by the chemicals used when latex gloves are made. This type of reaction is typically delayed 6 to 48 hours and includes dryness, pruritis, and cracking of the skin. The initial response is quickly followed by redness, swelling, and crusting. If exposure continues, lichenification, scaling, and hyperpigmentation occur. An allergic reaction to latex is a response to the natural rubber latex proteins and occurs within minutes of exposure. Manifestations vary from skin redness, urticaria, rhinitis, conjunctivitis, or asthma to a serious anaphylactic reaction and shock. Systemic diseases ?rheumatoid arthritis systemic lupus erythematosus ? Hematopoietic system ?autoimmune hemolytic anemia immune thrombocytopenic purpura ? Central nervous system ?Guillain-Barre syndrome multiple sclerosis ? Endocrine system ?Addison’s disease Grave’s disease diabetes mellitus type 1 ? Gastrointestinal system ?celiac disease inflammatory bowel disease ? Cardiovascular system ?rheumatic fever ? Renal system ?glomerulonephritis ? Liver ?autoimmune hepatitis primary biliary cirrhosis ? Musculoskeletal system ?myasthenia gravis ? Diabetes mellitus type 1 is thought to be triggered by a virus.? Rheumatic fever and rheumatic heart disease are triggered by streptococcal infections.? Hemolytic anemia can result from methyldopa administration?. Procainamide can induce the formation of antinuclear antibodies, causing a lupus-like syndrome. Abstaining from sexual activity is the most effective way to prevent exposure. ? Sexual activities that do not include the transference of body fluids (e.g., masturbation, mutual masturbation) are effective to prevent exposure. ? Sexual penetration between partners who are not infected and not at risk of infection is considered safe. The most commonly used barrier is the male condom, which offers protection during anal, vaginal, and oral intercourse. Female condoms are the alternative to male condoms. Do not use drugs!? If drugs are used, do not share equipment.? Do not have sexual intercourse when under the influence of drugs, which impairs decision making. Use standard precautions and personal protective equipment when anticipating contact with blood or body fluids.? Wash your hands immediately after contact with blood or body fluids.? Be careful when handling and disposing of sharp devices. Use safety devices to prevent needlestick injuries. ? Dispose of used syringes and other sharp instruments in a sharps container (CDC, 2019). monitoring disease progression and immune function ? initiating and monitoring antiretroviral therapy (ART)? preventing the development of opportunistic diseases? detecting and treating opportunistic diseases? managing symptoms? preventing or decreasing complications of treatment? preventing transmission of HIV?