A client asks, "Why does my leg swell when I have an infection?" How should the nurse respond?
1. "The fever from your infection causes you to drink more, and you become fluid overloaded."
2. "The infection causes the little vessels in your leg to become leaky, and fluid seeps out of your blood."
3. "The infection causes your lymphatic system to get blocked up so it doesn't drain."
4. "When you have an infection, more blood goes to your leg, causing it to swell."
Correct Answer: 2
Rationale 1: Although fluid overload can cause edema, it is not the cause of edema in inflammation.
Rationale 2: Increased capillary permeability allows plasma proteins such as antibodies and complement to exit the blood and enter the inflamed tissue. Water follows the proteins. Explanation to the client should be simple and use easily understandable terminology.
Rationale 3: Although blocked lymphatic drainage can cause edema, it is not the cause of edema in inflammation.
Rationale 4: Increased blood flow causes warmth and redness.
Global Rationale: The central purposes of inflammation are to contain the injury, destroy the pathogen, and initiate repair of the area. Histamine is a key chemical mediator of inflammation. When released at an injury site, histamine dilates nearby blood vessels, causing the capillaries to become more permeable. Plasma, complement proteins, and phagocytes can then enter the area to neutralize microbes or their toxins. The affected area may become congested with blood, which can lead to significant swelling and pain. This response is not related to the amount the patient is drinking, blocking of the lymphatic system, or extra blood in the leg.
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