Based on the initial assessment findings, which of the following indicates that the patient's surgical wound is healing normally?

B) Well-approximated wound edges

A) Presence of purulent drainage

B) Well-approximated wound edges

C) Excessively hot surrounding skin

D) Increased redness and swelling

What is the most appropriate nursing action based on the initial assessment findings of the surgical wound?

B) Continue monitoring the wound for signs of infection

A) Apply a cold compress to the wound site

B) Continue monitoring the wound for signs of infection

C) Increase the frequency of wound dressing changes

D) Immediately notify the physician of the findings

Which of the following observations indicates that the patient's surgical wound is healing appropriately?

B) Reduction in erythema and edema with well-approximated wound edges

A) Increased erythema and edema around the incision site

B) Reduction in erythema and edema with well-approximated wound edges

C) Increased drainage from the wound

D) Elevated skin temperature around the incision site

What is the primary indication that the patient's wound is healing properly?

C) Reduction in erythema and edema with no new drainage

A) Increased erythema and edema around the incision site

B) The patient's pain level increasing to 8 out of 10

C) Reduction in erythema and edema with no new drainage

D) Elevated temperature and increased heart rate

What is the primary reason the nurse assesses the patient's white blood cell count in relation to wound healing?

B) To assess for signs of systemic infection

A) To determine the patient's nutritional status

B) To assess for signs of systemic infection

C) To evaluate the patient's oxygen-carrying capacity

D) To check for electrolyte imbalances

A patient recovering from surgery reports a slight increase in tenderness around the wound site, with a pain level of 3 out of 10. The nurse observes a decrease in erythema and a small amount of serous drainage, with stable vital signs. Which action should the nurse take next?

B) Document the findings and reinforce wound care education

A) Notify the healthcare provider immediately

B) Document the findings and reinforce wound care education

C) Apply an antibiotic ointment to the wound

D) Increase the frequency of pain medication administration

Which observation indicates that the patient's surgical wound is healing well?

B) Reduction in serous drainage

A) Increased erythema around the wound

B) Reduction in serous drainage

C) Elevated white blood cell count

D) Presence of foul odor from the wound

Which of the following assessment findings most strongly indicates that the patient's surgical wound is healing properly?

B) Well-approximated wound edges

A) Increased erythema around the wound site

B) Well-approximated wound edges

C) A white blood cell count of 15,000/mm³

D) Presence of purulent drainage

What is the most important action for the nurse to take when the patient reports a pain level of 2 out of 10 during the follow-up visit?

B) Continue the current wound care regimen

A) Increase the patient's pain medication dosage

B) Continue the current wound care regimen

C) Schedule an immediate appointment with the physician

D) Advise the patient to stop all activities

What is the most appropriate action for the nurse to take based on the patient's current condition as described in the case section?

C) Encourage the patient to maintain the current wound care regimen

A) Discontinue the follow-up visits as the patient is healing well

B) Advise the patient to increase physical activity significantly

C) Encourage the patient to maintain the current wound care regimen

D) Recommend the patient stop monitoring the wound for changes

Surgical wound - Nursing Case Study

Pathophysiology

• Primary mechanism: Surgical wounds disrupt skin integrity, breaching the barrier that protects against infection. This invites pathogens, potentially leading to localized infection if not properly managed.

• Secondary mechanism: Inflammatory response is triggered, involving an influx of white blood cells to the site to combat potential pathogens. This response is crucial for wound healing but can cause redness, swelling, and warmth.

• Key complication: Minor complications include delayed healing due to infection, which can prolong recovery time and increase discomfort for the patient. Proper wound care and monitoring for signs of infection are essential in preventing these issues.

Patient Profile

Demographics:

25-year-old female, retail worker

History:

• Key past medical history: No significant past medical history

• Current medications: Ibuprofen 200 mg as needed for pain

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Mild pain and redness around the surgical wound

• Key symptoms: Slight swelling, tenderness at the incision site

• Vital signs: Temperature 98.6°F, Heart rate 78 bpm, Blood pressure 118/76 mmHg, Respiratory rate 16 breaths per minute

Section 1

Initial Assessment Findings:

During the initial assessment, the nurse observes the surgical wound closely. The incision site is clean but exhibits mild erythema and slight edema, consistent with the patient's report of redness and swelling. There is no purulent drainage, and the wound edges are well-approximated, indicating early-stage healing. The nurse notes that the surrounding skin is warm to touch but not excessively hot, suggesting a normal inflammatory response rather than a severe infection. The patient rates her pain at the incision site as 3 out of 10 on a pain scale when at rest, with slight increases in discomfort during movement.

The patient's vital signs remain stable, with a temperature of 98.6°F, heart rate of 78 bpm, blood pressure of 118/76 mmHg, and respiratory rate of 16 breaths per minute, indicating no systemic infection. Upon further inquiry, the patient mentions adhering to the prescribed wound care regimen and taking ibuprofen as needed for pain, which provides adequate relief. The nurse educates the patient on the importance of maintaining the wound care routine, observing for any changes such as increased redness, drainage, or fever, and continuing to take analgesics as prescribed to manage pain effectively.

These findings suggest that while there is a mild localized inflammatory response, there is no current evidence of significant infection. The nurse plans to continue monitoring the wound site and the patient's overall condition closely, ensuring that any potential complications can be addressed promptly. This assessment guides the next steps in the patient's care, focusing on continued wound care, pain management, and education to prevent infection and promote healing.

Section 2

Response to Interventions:

Over the next 48 hours, the nurse continues to monitor the patient's surgical wound and overall condition, focusing on the effectiveness of the current interventions. The patient diligently follows the wound care regimen, including cleaning the site with saline and applying a prescribed topical antibiotic ointment. During this period, the patient reports feeling more comfortable, with her pain level consistently at a 2 out of 10, even during movement. This suggests that the pain management strategy, including ibuprofen as needed, is effective.

On reassessment, the nurse observes a reduction in the erythema and edema around the incision site, indicating a positive response to the interventions. The wound edges remain well-approximated, and there is no new drainage or signs of infection. The surrounding skin temperature is now slightly cooler, further supporting the resolution of the initial mild inflammatory response. The patient's vital signs remain stable, with a temperature of 98.4°F, heart rate of 76 bpm, blood pressure of 116/74 mmHg, and respiratory rate of 16 breaths per minute. These findings provide reassurance that the localized inflammation is diminishing and that the wound is healing appropriately.

The nurse discusses these positive developments with the patient, reinforcing the importance of continued adherence to the wound care protocol and timely pain management. She also reminds the patient to watch for any new symptoms or changes in the wound and to report these immediately. This continued education helps empower the patient to actively participate in her recovery, reducing the risk of complications and promoting a smooth healing process. As the patient's condition remains stable and improves, the care plan focuses on maintaining this trajectory, preparing for the eventual transition to less intensive follow-up care.

Section 3

Over the subsequent 24 hours, the nurse continues to monitor the patient closely, noting any changes in the wound and the patient's overall condition. During this period, the patient reports a slight increase in tenderness around the wound site, although her pain level remains manageable at a 3 out of 10. The nurse carefully inspects the wound and observes that while the erythema has decreased, there is a small amount of serous drainage present. The wound edges remain well-approximated, and there is no odor or significant increase in swelling, suggesting that the drainage may be a normal part of the healing process rather than a sign of infection.

To ensure comprehensive care, the nurse decides to review the patient's laboratory results, focusing on her white blood cell count, which is within the normal range at 7,500/mm³. This finding, combined with the stable vital signs—temperature of 98.6°F, heart rate of 78 bpm, blood pressure of 118/76 mmHg, and respiratory rate of 16 breaths per minute—supports the assessment that there is no systemic infection present. The nurse documents these findings and reinforces to the patient the importance of continuing her wound care regimen and monitoring for any changes.

Given the stable condition and minor drainage, the nurse collaborates with the healthcare team to adjust the care plan slightly, incorporating additional patient education on signs of infection and the significance of drainage. The patient is encouraged to continue observing her wound for any changes in color, amount, or odor of the drainage, and to maintain her current pain management strategy. This proactive approach aims to prevent any potential complications and ensures the patient feels confident in managing her recovery at home, with the support of scheduled follow-up appointments to monitor her progress.

Section 4

A few days later, during a routine follow-up appointment, the nurse assesses the patient's surgical wound to evaluate the progress of healing. The patient reports that her pain level has slightly decreased to a 2 out of 10, and she has been adhering to the wound care regimen as instructed. Upon inspection, the nurse notes that the serous drainage has reduced significantly, and the erythema around the wound site is minimal. The wound edges remain well-approximated, and there is still no odor or significant swelling, suggesting satisfactory healing.

The nurse reviews the latest laboratory results, which show a stable white blood cell count of 7,400/mm³, indicating that there is no emerging infection. The patient's vital signs are consistent with previous readings: a temperature of 98.7°F, heart rate of 76 bpm, blood pressure of 116/74 mmHg, and respiratory rate of 15 breaths per minute. These findings reinforce the conclusion that the patient's condition remains stable, with no signs of systemic infection or complications.

Given the positive response to interventions, the nurse provides positive reinforcement to the patient, praising her adherence to the wound care plan. They discuss the importance of maintaining the current regimen and continue monitoring for any signs of infection or complications. The patient is reassured that her healing is progressing well and is encouraged to contact the healthcare team if she notices any changes in her condition. The nurse schedules the next follow-up appointment to ensure ongoing evaluation and support as the patient continues her recovery journey.

Section 5

A week later, the patient returns for her scheduled follow-up appointment. During the initial assessment, the nurse notes that the patient continues to report a pain level of 2 out of 10, consistent with the previous visit. The patient mentions she has been engaging in light activities as advised and continues to follow the wound care regimen diligently. Upon inspection, the nurse observes further improvement in the wound's appearance; the serous drainage has nearly ceased, and the erythema has resolved completely. The wound edges remain well-approximated, and there are no signs of discharge, odor, or swelling.

The nurse reviews the patient's latest laboratory results, which confirm continued stability: a white blood cell count remains at 7,300/mm³, and all other parameters remain within normal limits. The patient's vital signs are reassuring, with a temperature of 98.5°F, heart rate of 74 bpm, blood pressure of 114/72 mmHg, and respiratory rate of 16 breaths per minute. These findings indicate that the healing process is progressing smoothly, with no evidence of infection or other complications.

In light of these positive developments, the nurse discusses with the patient the possibility of gradually increasing her activity level, while ensuring she continues to listen to her body and rest as needed. The importance of monitoring the wound for any changes, such as increased redness, swelling, or discharge, is reiterated. The patient is encouraged to maintain her current care routine and advised to report any concerns promptly. The nurse schedules another follow-up visit to continue monitoring the patient's recovery, ensuring that healing remains on track and providing support as she transitions back to her usual activities.