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 contaminati...
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.
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