A nursing officer noting pus, redness, pain, swelling and hardness at wound site while changing wound dressin… - NORCET 3 - 2022 (Shift-2)

NORCET 3 - 2022 (Shift-2)

Medical & Surgical Nursing

Easy

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

Explanation

The question describes the five cardinal signs of local inflammation and infection: rubor (redness), tumor (swelling), calor (warmth, implied by inflammation), dolor (pain), and functio laesa (loss of function, implied by the wound).
The presence of pus (purulent drainage) is a hallmark sign of a bacterial infection, as it consists of dead bacteria, white blood cells, and tissue fluid.
According to wound healing principles, local signs such as erythema (redness), periwound warmth, pain, edema (swelling), and a change in drainage to a thick, colored, or odorous fluid are indicative of a wound infection.

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 and discoloration, the other signs like purulent discharge are absent.
Option C: Keloid formation is an overgrowth of scar tissue that occurs during the maturation phase of healing, weeks or months after the initial injury. It presents as a firm, raised scar and is not associated with acute signs like pus, redness, and pain.
Option D: Granulation tissue is a sign of healthy wound healing, not a complication. It appears as beefy red, moist, and bumpy tissue in the wound bed, indicating the growth of new blood vessels and connective tissue.

Visual 1: Infographic - A chart comparing the visual characteristics of an infected wound (pus, redness, swelling), a hemorrhaging wound (active bleeding), a keloid (raised scar), and a healthy granulating wound (beefy red tissue).
Visual 2: Diagram - An illustration showing the inflammatory process at a cellular level in an infected wound, highlighting the roles of neutrophils, bacteria, and vasodilation.

Clinical Relevance

Nursing practice connection: Knowing Assessment of Wound Complications helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Early recognition of wound infection is a critical nursing responsibility to prevent complications such as cellulitis, abscess formation, or systemic infection (sepsis).
Nursing actions upon identifying signs of infection include: performing a full wound assessment, obtaining a wound culture as ordered (before starting antibiotics), notifying the healthcare provider, and initiating appropriate wound care using aseptic technique.
Patient education is vital. The nurse should teach the patient and family to identify signs of infection and to report them promptly.

How to Approach the Question

First, carefully read the clinical scenario and identify the key assessment findings presented in the stem: pus, redness, pain, swelling, and hardness.
Recognize that this cluster of signs represents the classic cardinal signs of inflammation.
Evaluate each option against these findings. The term 'pus' is the most specific and powerful clue.
Option A (Infection): Pus is a definitive sign of infection. The other signs (redness, pain, swelling) are also consistent with infection.
Option B (Haemorrhage): This means bleeding. The key finding would be blood, not pus.
Option C (Keloid formation): This is a type of scarring that occurs long after healing and does not involve pus or acute inflammation.

Concept Tested & Keywords

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