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문제

A nurse is assessing a postoperative patient's surgical wound on the second day after abdominal surgery. Which assessment finding would be most concerning and require immediate intervention?

해설
Wound dehiscence with visible subcutaneous tissue and a 2 cm gap is most concerning as it indicates a serious complication requiring immediate intervention to prevent evisceration. Other findings like serosanguineous drainage, mild erythema, or moderate pain are expected postoperative signs.
같은 주제 다음 문제A nurse is assessing a surgical wound on postoperative day 5. Which finding would indicate…

심화 해설

Clinical Reasoning and Priority Setting

This question tests your ability to recognize postoperative complications and prioritize nursing interventions. The key is distinguishing between expected inflammatory responses and a serious wound complication that threatens tissue viability and increases infection risk.

Analysis of Findings

Postoperative wound healing follows a predictable trajectory. On the second day after abdominal surgery, the inflammatory phase is active, making some findings expected. However, a disruption in the wound closure represents a failure of the healing process that demands immediate action.

- Serosanguineous drainage (Option 1) is a normal finding during the inflammatory phase of healing. A small amount of pink-tinged fluid consists of serum and a small number of red blood cells, which is expected as capillaries in the wound bed remain slightly permeable . This does not indicate a complication requiring intervention beyond routine dressing management.

- Mild erythema extending 1-2 cm from the wound edges (Option 2) reflects localized vasodilation and increased capillary permeability, which are necessary components of the inflammatory response that brings immune cells and nutrients to the healing tissue . This finding is expected and does not signal infection unless accompanied by purulent drainage, increasing erythema beyond 2 cm, or systemic signs.

- A pain level of 6/10 with movement (Option 3) is anticipated on postoperative day two. Incisional pain is caused by tissue trauma, edema, and the stimulation of nociceptors during the inflammatory phase. Movement places mechanical stress on the suture line, predictably increasing discomfort . This requires ongoing pain management but is not a surgical emergency.

- Separation of wound edges with visible subcutaneous tissue and a gap of 2 cm (Option 4) describes wound dehiscence. This is the most concerning finding because the protective barrier function of the closed incision is lost. When the epidermal and dermal layers separate, underlying subcutaneous tissue is exposed to the external environment, dramatically increasing the risk for surgical site infection (SSI) . SSI is associated with prolonged hospitalization, readmission, increased healthcare costs, and adverse clinical outcomes, making prevention and early detection of wound integrity loss a critical nursing responsibility .

Why Immediate Intervention is Required

Wound dehiscence demands urgent nursing action because the open wound creates a direct portal of entry for microorganisms. Perioperative nursing surveillance extends into the postoperative phase, where ongoing wound assessment is essential for early identification of healing disruptions . A dehisced wound requires sterile coverage with a moist dressing to protect exposed tissue, notification of the surgical team, and preparation for possible surgical re-closure. Delaying intervention allows for bacterial contamination, tissue desiccation, and progression to evisceration, a life-threatening extension of dehiscence where abdominal contents protrude through the wound. The nurse's systematic assessment and prompt recognition of this deviation from expected healing directly influence the patient's trajectory toward recovery or complication .

임상 시나리오

Clinical Practice Guide: Managing Postoperative Wound Dehiscence

Wound dehiscence is a serious surgical complication involving the separation of fascial layers, potentially leading to evisceration. On the second postoperative day, a gap of 2 cm with visible subcutaneous tissue indicates a failure of wound closure that requires immediate action to prevent infection, further tissue damage, and evisceration.

Immediate Nursing Actions
  • Stay with the patient and call for help. Do not leave the patient unattended.
  • Cover the wound with sterile, saline-moistened gauze to keep exposed tissue from drying out. Use sterile technique strictly.
  • Position the patient supine with knees slightly bent (low Fowler's or semi-Fowler's) to reduce tension on the abdominal incision.
  • Notify the surgeon immediately and prepare the patient for a possible return to the operating room for surgical re-closure.
  • Monitor vital signs frequently, assessing for signs of shock or infection, and keep the patient NPO in anticipation of surgery.
Ongoing Assessment and Prevention
  • Instruct the patient to avoid coughing, straining, or sudden movements. Teach splinting of the incision with a pillow when coughing or deep breathing.
  • Assess for risk factors such as obesity, malnutrition, diabetes, smoking, or prolonged steroid use that impair wound healing.
  • Document the size, depth, and appearance of the wound separation, along with the time of discovery and interventions performed.
  • Provide emotional support, as the patient may experience anxiety or fear upon seeing the open wound.

핵심 개념

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