HNN227 EXAM GUIDE 2024/2025 WITH GUARANTEED ACCURATE ANSWERS |VERIFIED
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Course
HNN227
Institution
HNN227
Define: Inflammation - ACCURATE ANSWERInflammation is an adaptive response to injury that brings fluid, dissolved substances and blood cells into the interstitial tissues where the invasion
or damage has occurred.
Pathophysiology: Inflammation process - ACCURATE ANSWERStages:
(1) Vasodilation...
HNN227 EXAM GUIDE 2024/2025
HNN227 EXAM GUIDE 2024/2025 WITH GUARANTEED ACCURATE ANSWERS |
VERIFIED
Define: Inflammation - ACCURATE ANSWER✅✅Inflammation is an
adaptive response to injury that brings fluid, dissolved substances and
blood cells into the interstitial tissues where the invasion
or damage has occurred.
Pathophysiology: Inflammation process - ACCURATE
ANSWER✅✅Stages:
(1) Vasodilation
(2) Vascular permeability
(3) Exudation
(4) Clotting
(5) White blood cells and phagocytes
,• Mast cells release histamines and prostaglandins.
• Histamines and prostaglandins induce vasodilation of capillaries to
increase blood flow.
• Results in the two cardinal signs of Redness and Heat.
• Fluid moves out of blood vessels and surrounds the injured site.
• Results in the two cardinal signs of Swelling and Pain.
• Collagen enters the site and activates the clotting cascade.
• Clotting cascade creates a fibrin meshwork; which creates a seal over
the damaged tissue.
• Phagocytes and WBC centre damaged tissue, engulfing necrotic
tissues and pathogens - cleaning up the area.
Role of Nurse: Inflammation - ACCURATE ANSWER✅✅• Identify
the signs and symptoms of inflammation (Red, Heat, Swelling
and Pain)
• Immediate treatment of inflammation (Encourage RICE and
Immobilisation)
• Assess need for analgesia
• Assess need for NSAIDs
• Offer hot or cold compress
Actual problem: Acute pain related to inflammation of ... - ACCURATE
ANSWER✅✅Assess: site, severity and radiation of pain, utilising
pain scoring tools, record and report significant changes.
,Interventions:
• Assist to position of comfort
• Safely administer medications as ordered/monitor response (e.g.
analgesics)
• Elevate limb
• Ice to area
Potential problem: Potential for impaired skin Integrity related to the
inflammatory response. - ACCURATE ANSWER✅✅Assess: site,
severity and radiation of pain, utilising pain scoring tools, record and
report significant changes.
Interventions:
• Elevate lower limb
• Provide hygiene assistance
• Dress wound if applicable
• Immobilisation of lower leg
• IV antibiotic therapy as ordered
Actual problem: Anxiety related to lack of knowledge and hospital
admission. - ACCURATE ANSWER✅✅Assess: knowledge regarding
ward procedures and inflammation
Interventions:
, • Provide education
• Provide support
• Refer to appropriate allied health member
Potential problem: Risk of falls related to age and presence of acute
illness, unsteady gait, antihypertensive agents and unfamiliar
environment. - ACCURATE ANSWER✅✅Assess: falls risk
assessment
Interventions:
• Falls alert - band/chart
• Keep area clean and uncluttered
• Reorientate as required to TPP
• Monitor for signs of dizziness.
Actual problem: Disturbed body image related to changes in the form of
one limb. - ACCURATE ANSWER✅✅Assess: assess perception of
change in structure or function of body part; Assess perceived impact of
change on activities of daily living (ADLs), social behaviour, personal
relationships, and occupational activities.
Interventions:
• Assist patient in incorporating actual changes into ADLs, social life,
interpersonal relationships, and occupational activities.
• Help patient identify actual changes.
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