NORCET 3 - 2022 (Shif…: A nursing officer noting pus, redness, pain, swelling and hardness at wound site while changing wound dressin…

NORCET 3 - 2022 (Shift-2)

Medical & Surgical Nursing

Easy

Appeared in: NORCET 3 - 2022 (Shift-2)

Explanation

The combination of pus, redness, pain, swelling, and hardness are the classic local signs of a wound infection.
Pus, or purulent drainage, is a definitive sign of infection, resulting from the accumulation of dead bacteria, white blood cells, and tissue debris.
Redness (erythema), pain, swelling (edema), and warmth are caused by the inflammatory response, where blood vessels dilate to bring immune cells to the site of injury to fight microorganisms.
Hardness (induration) around the wound is due to the collection of fluid and cellular infiltrates in the tissue as part of the inflammatory process.

Option B: Haemorrhage is characterized by active bleeding (sanguineous drainage), not the presence of pus. While a hematoma (a collection of blood) can cause swelling, the primary sign is blood, not purulent exudate.
Option C: Keloid formation is an abnormal, excessive growth of scar tissue that occurs well after the initial wound healing phase. It is a firm, raised scar and is not associated with acute signs of infection like pus, redness, and pain.
Option D: Granulation tissue is a sign of healthy wound healing, not infection. It appears as pink or beefy red, moist, bumpy tissue in the wound bed. It does not involve pus or the other inflammatory signs described.

Clinical Relevance

Nursing practice connection: Knowing Recognition of wound infection signs helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Early recognition and management of wound infections are critical nursing responsibilities to prevent complications such as delayed healing, tissue destruction, and systemic infection (sepsis), which can be life-threatening.
Nurses must use strict aseptic technique when performing wound care to prevent introducing pathogens. If an infection is suspected, the nurse should obtain a wound culture before administering antibiotics to ensure the correct pathogen is targeted.
What if? If the nurse noted a beefy red, bumpy wound bed that bled easily with minimal clear drainage and no pus, this would indicate healthy granulation tissue. The nursing action would be to continue with appropriate wound care to support healing, rather than treating an infection.

How to Approach the Question

First, analyze the clinical signs presented in the question: pus, redness, pain, swelling, and hardness.
Recall the five cardinal signs of inflammation and infection: rubor (redness), tumor (swelling), calor (heat/warmth), dolor (pain), and functio laesa (loss of function). Note that the signs in the question match these closely.
Recognize that the presence of pus (purulent exudate) is a definitive indicator of a bacterial infection.
Evaluate each option: 'Haemorrhage' is bleeding. 'Keloid formation' is late-stage scarring. 'Granulation tissue' is healthy healing. None of these match the full set of signs.
Conclude that the collection of signs points directly to 'Infection' as the only plausible diagnosis.

Concept Tested & Keywords

Concept Tested: Recognition of wound infection signs
Stem keywords: wound dressing, pus, redness, pain, swelling, hardness, wound site
Lead-in keywords: indicate to
Clinical cues: The presence of multiple classic signs of inflammation (redness, pain, swelling) combined with pus is a strong indicator of infection.
Negative lead-in flag: false