# A nurse is assessing a surgical wound on postoperative day 3. Which finding would indicate that the wound is progressing normally through the inflammatory phase of healing?

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## 문제

A nurse is assessing a surgical wound on postoperative day 3. Which finding would indicate that the wound is progressing normally through the inflammatory phase of healing?

## 보기

1. Slight redness and warmth around the incision with minimal clear drainage **✔ 정답**
2. Absence of any redness or swelling with dry wound edges
3. Thick yellow drainage with strong odor and increased pain
4. Cool, pale skin around the incision with no drainage

**정답: 1**

## 해설

During the inflammatory phase (days 1-4), normal findings include slight redness, warmth, and minimal clear drainage, indicating proper healing initiation. Other options describe abnormal or later phase findings.

## 심화 해설

Understanding the Inflammatory Phase

Wound healing is a highly orchestrated biological process, and the inflammatory phase is the critical first stage that begins immediately after tissue injury. This phase is not a sign of infection but a necessary and beneficial response. Its purpose is to achieve hemostasis, remove debris and bacteria, and set the stage for new tissue formation. High-frequency ultrasound (HFUS) studies have allowed us to visualize this process non-invasively, showing that this phase corresponds to specific changes in dermal composition and vascularity [1]. The coordinated interactions among inflammatory cells, growth factors, and extracellular matrix components that define this phase are fundamental to the entire healing cascade [2].

Analyzing the Correct Answer (Option 1)

The finding of slight redness and warmth around the incision with minimal clear drainage on postoperative day 3 is a classic and expected presentation of a normal inflammatory phase. This occurs because of:

- Vasodilation: Injured cells release chemical mediators like histamine, causing local blood vessels to widen. This increases blood flow to the area, which clinically manifests as redness (rubor) and warmth (calor).

- Increased Vascular Permeability: The vessel walls become more permeable, allowing fluid, proteins, and white blood cells (especially neutrophils and macrophages) to leak into the interstitial space. This results in localized swelling (tumor) and the production of clear, serous drainage. This fluid is rich in growth factors and immune cells essential for wound cleansing, reflecting the complex biological process described in translational human wound models [2].

The key is that these signs are slight and the drainage is minimal and clear. HFUS evaluation of surgical wounds during this phase would show increased dermal thickness and enhanced blood flow signals, confirming this as a normal, active healing state [1].

Why the Other Options Are Incorrect

- **Option 2:** Absence of any redness or swelling with dry wound edges is not typical for day 3. The inflammatory phase is a prerequisite for subsequent proliferation. A completely "quiet" wound with no signs of inflammation at this stage might suggest an impaired healing response, such as in an immunocompromised patient, rather than a normal progression. The biological process of healing involves a complex, coordinated inflammatory response that is visibly active [2].

- **Option 3:** Thick yellow drainage with strong odor and increased pain is a hallmark of wound infection, not normal inflammation. While inflammation is part of healing, an infection represents an overwhelming bacterial burden that prolongs the inflammatory phase and destroys tissue. The purulent (yellow, thick) drainage consists of dead neutrophils, bacteria, and cellular debris, and the strong odor and escalating pain are cardinal signs that the biological balance has shifted from repair to pathology.

- **Option 4:** Cool, pale skin around the incision with no drainage indicates poor tissue perfusion. Adequate blood supply is essential for delivering the inflammatory cells and growth factors required for healing. Cool, pale skin suggests vasoconstriction or impaired circulation, which would severely compromise the inflammatory phase and the entire subsequent healing process.

Clinical Application for the NCLEX-RN

When assessing a surgical wound, your clinical judgment must differentiate between the normal, expected signs of the inflammatory phase and the abnormal signs of a complication like infection or ischemia. The inflammatory phase is a sign that the complex biological interactions among cells, growth factors, and the extracellular matrix are proceeding as intended [2]. Your assessment should focus on the degree and quality of these findings. A slight, localized response with serous drainage is a positive indicator, while a spreading, purulent, or ischemic presentation requires immediate intervention. This distinction is fundamental to safe and effective nursing care across all client need categories.

References (research sources)

- [1]High-Frequency Ultrasound Evaluation of Cutaneous Surgical Wound Healing: An Outpatient Experience.Research articleRusso A, Patanè V, Bucciero L, Pezzella MC, Brunese M, Stanzione F, Faenza M, Reginelli A. (2026) · DOI: 10.1111/wrr.70136

- [2]Open Pilonidal Excision as a Translational Human Model for Wound Healing and Skin Regeneration Research.Research articleVardakostas D, Garoufalia Z, Philippou A, Mantas D. (2026) · DOI: 10.3390/biomedicines14040751

## 임상 시나리오

Normal Inflammatory Phase AssessmentPostoperative Day 3 Wound Evaluation
On postoperative day 3, a healing surgical wound is typically in the late inflammatory phase. Expect localized redness and warmth confined to the incision margins, caused by vasodilation.

Minimal clear or serosanguinous drainage is a normal finding. This fluid is rich in growth factors and immune cells essential for debridement and initiating the proliferative phase.

CautionDo not confuse normal inflammatory signs with infection. Infection indicators include thick, yellow/green drainage, foul odor, increasing pain, and erythema spreading beyond 1-2 cm from the wound edges. Cool, pale skin suggests ischemia and requires immediate intervention.

## 핵심 개념

- **Inflammatory Phase** — The initial stage of wound healing immediately after injury, characterized by hemostasis, vasodilation, increased vascular permeability, and the arrival of neutrophils and macrophages to clear debris and bacteria.
- **Vasodilation** — The widening of blood vessels, mediated by histamine and other chemical signals, which increases local blood flow and causes the clinical signs of redness (rubor) and warmth (calor).
- **Serous Drainage** — Clear, watery plasma drainage that is a normal finding during the inflammatory and early proliferative phases of wound healing.
- **Purulent Drainage** — Thick, yellow, green, or brown drainage containing pus, leukocytes, and bacteria, which is indicative of wound infection.
- **Rubor** — Redness of the skin, one of the five cardinal signs of inflammation (along with calor, tumor, dolor, and functio laesa), caused by vasodilation and increased blood flow.

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