# A nurse is assessing a surgical wound on postoperative day 2. Which assessment finding indicates the wound is progressing through the inflammatory phase of healing as expected?

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## 문제

A nurse is assessing a surgical wound on postoperative day 2. Which assessment finding indicates the wound is progressing through the inflammatory phase of healing as expected?

## 보기

1. Presence of granulation tissue with a beefy red appearance
2. Wound edges that are well-approximated with minimal drainage
3. Formation of a thin, pale pink scar tissue
4. Erythema and edema around the wound with serosanguineous drainage **✔ 정답**

**정답: 4**

## 해설

In the inflammatory phase (days 3-5), expected findings include erythema, edema, and serosanguineous drainage. Other options describe proliferative or maturation phase findings.

## 심화 해설

Understanding the Inflammatory Phase

The inflammatory phase is the body's immediate and essential first response to tissue injury, such as a surgical incision. It typically begins at the moment of injury and lasts for approximately 2 to 5 days. The clinical signs you observe are direct manifestations of the underlying cellular and vascular activities required to clean the wound and prepare it for new tissue formation. As noted in the literature, acute wounds "progress through orderly phases of repair," beginning with a tightly regulated inflammatory signaling cascade [3].

Analysis of the Correct Answer (Option 4)

Erythema (redness) and edema (swelling) around the wound, accompanied by serosanguineous drainage, are the classic, expected indicators of a normal inflammatory response on postoperative day 2. These signs are not complications; they are visual proof that the healing cascade is working.

- Erythema and Heat: Result from local vasodilation, which increases blood flow to deliver oxygen, nutrients, and essential immune cells like neutrophils and macrophages to the injury site.

- Edema: Occurs as blood vessels become more permeable, allowing plasma and leukocytes to leak into the interstitial space. This fluid accumulation causes the characteristic swelling.

- Serosanguineous Drainage: This type of drainage is a direct product of the inflammatory process. It is a mixture of serum (the clear, straw-colored fluid portion of blood from increased permeability) and a small amount of red blood cells, giving it a pinkish tinge. This indicates that the microvasculature is effectively delivering the cellular components needed for wound debridement and bacterial defense.

This process is fundamental in acute surgical wounds, where the biological goal is to trigger the "initiation of regeneration" [1]. The coordinated immune response described here is a dynamic process that prevents the wound from becoming arrested in a non-healing state [3].

Analysis of Incorrect Options

- Option 1: The presence of granulation tissue with a "beefy red" appearance is a hallmark of the proliferative phase of healing, not the inflammatory phase. This phase, characterized by angiogenesis (new blood vessel formation) and extracellular matrix reconstruction, occurs after the inflammatory phase has successfully prepared the wound bed . Seeing this on day 2 would be premature.

- Option 2: Well-approximated wound edges with minimal drainage describe the final stage of healing, the maturation or remodeling phase, or a wound that has healed by primary intention without complication. This finding is expected much later in the postoperative course, after collagen has been deposited and remodeled to strengthen the wound.

- Option 3: The formation of a thin, pale pink scar is a late sign of the maturation phase. During this phase, collagen is reorganized, and the scar's vascularity decreases, causing it to lighten and flatten over weeks to months. This is the final outcome of the healing process, not an event occurring on day 2.References (research sources)

- [1]Maintenance Debridement in Chronic Hard-to-Heal Wounds: Toward Dynamic Homeostasis and Precision Intervention.Research articleLu R, Zhang Y, Cheng B. (2026) · DOI: 10.1111/iwj.70930

- [3]Deciphering skin architecture, wound pathophysiology and molecular mechanisms of healing: insights into immune response and therapeutic strategies.Research articleMaan M, Joshi S, Saini A. (2026) · DOI: 10.3389/fbioe.2026.1812108

## 임상 시나리오

Postoperative Wound Assessment: Inflammatory PhaseRecognizing Normal Healing on Day 2
The inflammatory phase is the first stage of wound healing, lasting 2 to 5 days post-injury. The cardinal signs are redness, swelling, localized heat, and pain, resulting from vasodilation and increased capillary permeability.

Expected drainage during this phase is serosanguineous—a thin, watery, pinkish fluid composed of serum and a small amount of red blood cells. This indicates the body's immune cells are actively cleansing the wound bed.

CautionDo not confuse normal inflammatory redness with infection. Infection typically presents with increasing pain, purulent drainage, foul odor, and expanding redness beyond the wound edges after day 3-4.

## 핵심 개념

- **Inflammatory Phase** — The initial phase of wound healing lasting 2-5 days, characterized by hemostasis, vasodilation, and phagocytosis to control bleeding and prevent infection.
- **Serosanguineous Drainage** — Thin, watery drainage that is blood-tinged, composed of serum and red blood cells, commonly seen during the inflammatory phase of healing.
- **Erythema** — Redness of the skin caused by increased blood flow (hyperemia) due to vasodilation in the injured area.
- **Edema** — Localized swelling caused by the leakage of fluid from increased capillary permeability into the interstitial spaces at the wound site.
- **Granulation Tissue** — New connective tissue and microscopic blood vessels that form during the proliferative phase, appearing beefy red and bumpy.

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