ADVENTIST MEDICAL CENTER COLLEGE

SAN MIGUEL, ILIGAN CITY

NAME: MABA, APIPAH S. DATE: 26TH OF AUGUST, 2021 SECTION: BSN3A

MACMAC, ANISA A.
MADELO, DIVYNNE B.
MANLANGIT, NATASHA P.
MAYO, JOHANISAH M.
MEDINA, DONEVA LYN B.
MEJIA, AIRA SHANELLE C.
MIRA, MARIVY ELLA P.
MONTERO, AMBER DAWN M.

CASE STUDY.
Mary Magdalene stepped on a nail 5 days ago and sustained a puncture about 1 inch deep. She
immediately cleaned the area with soap and water and hydrogen peroxide, and applied triple
antibiotic ointment to the site. Today she comes to the clinic with complaints of increased pain
and swelling in her foot. On assessment, the nurse notes that the puncture site is red and
edematous, and has a moderate amount of yellowish drainage.

a. Describe the sequence of events that caused the local inflammation seen in Mary’s foot.
Vasodilatation

Increased blood flow Increased vascular permeability

Slowing of blood in the vessel lumen

Increased viscosity

Engorgement of small vessels (stasis)

b. What is the role of histamine and kinins in the inflammatory process?

Histamine and kinins cause vasodilation and enhance vascular permeability during the early
transient phase of an inflammatory process. Histamine is an important regulator of itching,
and it's also released in response to stimulation by certain components of the complement
system. Kinins have a role in edema formation and once activated, they play a role in
chemotaxis by attracting phagocytic granulocytes, primarily neutrophils, to the injured area.

c. Which of the five cardinal signs of inflammation does Mary exhibit?

Mary exhibit tumor (swelling), calor (increased heat), she is also displaying rubor (redness)
and dolor (pain).

d. Because Mary’s injury occurred 5 days ago, the nurse should assess for what systemic
effects?
The nurse should assess for signs and symptoms of infection.
e. Give your interventions to Mary.
 The basics of wound care
Stop the bleeding: Minor puncture wounds and cuts usually stop bleeding without any
treatment. If not, apply gentle pressure with a clean cloth or bandage. If the blood spurts or
continues after several minutes of pressure, emergency care is necessary.
Clean the wound: The person that cleans the wound needs first to wash their hands; ideally, the
person should wear sterile gloves. People may spread bacteria into the wound if their hands are
not clean. Cleanse the wound; wash with water. People can use a mild soap such as Ivory if the
wound is very dirty. If dirt or debris remains in the wound, clean a pair of tweezers with alcohol,
and remove the dirt. If a person cannot get the dirt or debris out, the patient's doctor should be
notified or they should go to urgent care or emergency center.
Protect the wound: An antibiotic ointment such as Neosporin or Polysporin can be used. Apply a
thin layer over the wound. This will help coat and protect the wound. Large amounts of
ointment are not helpful because they can attract bacteria. Apply the ointment with a clean
swab or gauze. Do not apply directly from the tube in order to avoid contamination of the tube.
Ointments can be applied up to 3 times a day, but individuals should always clean the wound
before applying ointment.

 Clean the wound and remove any dirt or debris to prevent infections, both bacterial skin
infections and tetanus ("lockjaw").
 Determine whether you need a tetanus shot. If the injured person hasn't had a tetanus
shot in the past five years and the wound is deep or dirty, your doctor may recommend a
booster. The injured person should have the booster shot within 48 hours of the injury.