While changing the dressing, the nurse inspects that the wound area has become red with swelling and induration. What is the possible complication?

1. A

   Inflammation

2. B

   Evisceration

3. C

   Dehiscence

4. D

   Infection

Appeared in: NORCET 2 - 2021 (shift-1)

Explanation

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• The combination of redness (erythema), swelling (edema), and induration (hardening of tissue) are classic local signs of a wound infection.
• While inflammation is a normal part of healing, it is characterized by mild redness and swelling that typically subsides. The addition of induration points towards a pathological process.
• Infection occurs when microorganisms invade the wound tissue, leading to an exaggerated inflammatory response that includes these signs.
• Other signs of infection can include increased pain, warmth around the site, purulent drainage (pus), and systemic symptoms like fever.

Why Other Options Were Wrong

• Option A: Inflammation is a normal phase of wound healing, characterized by redness and swelling. However, the presence of induration (hardening) suggests the process has progressed beyond normal inflammation to an infection.
• Option B: Evisceration is the protrusion of internal organs through a wound opening. The signs described (redness, swelling, induration) are not characteristic of evisceration.
• Option C: Dehiscence is the separation of the wound edges. While infection can lead to dehiscence, the primary signs described (redness, swelling, induration) point directly to infection as the underlying complication.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Assessment of Postoperative 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 more severe complications like sepsis, dehiscence, or tissue necrosis.
• Nurses must use aseptic technique during dressing changes to prevent introducing microorganisms that can cause infection.
• What if? If the patient reported these signs on day 2 post-op without induration or purulent drainage, it would more likely be the normal inflammatory phase of healing. The presence of induration is the key sign that points towards infection.

How to Approach the Question

• First, identify the key clinical signs presented in the scenario: redness, swelling, and induration.
• Next, consider the provided options and recall the definition of each wound complication.
• Differentiate between the normal inflammatory process and a pathological infection. Note that inflammation is a part of infection, but infection is a more severe state.
• Analyze the specific sign 'induration.' This hardening of tissue is a strong indicator of an infectious process, distinguishing it from simple inflammation.
• Eliminate options that do not match the signs. Dehiscence (wound separation) and evisceration (organ protrusion) have very different presentations.
• Conclude that the combination of all three signs is most consistent with an infection.

Concept Tested & Keywords

• Concept Tested: Assessment of Postoperative Wound Complications
• Stem keywords: changing the dressing, wound area, red, swelling, induration
• Lead-in keywords: possible complication
• Clinical cues: The combination of redness, swelling, and induration is a key diagnostic cluster for infection.

Question ID

Qk6Mxsjf4gL1desDqho5pT

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 6 pp. 74-76, 81-83