# Stage 3 — Prioritize hypotheses. Mr. B, who has diabetes and obesity, is on postoperative day 5 after colorectal surgery; prophylactic antibiotics stopped after incision closure. Overnight he developed a temperature of 38.6 C with heart rate 102/min; BP is 124/76 mm Hg and lactate 1.4 mmol/L. Yesterday afternoon the incision was intact and dry; it now has purulent yellow drainage saturating the dressing, erythema extending 5 cm with increasing incisional tenderness, and two loose staples at the draining area without a gap through deeper layers. The abdomen is soft without rigidity or crepitus. He is alert, tolerating a diet, and ambulating with assistance. WBC has risen from 9.2 to 16.8 x 10^9/L with neutrophilia, and glucose is 246 mg/dL. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

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## Question

Stage 3 — Prioritize hypotheses. Mr. B, who has diabetes and obesity, is on postoperative day 5 after colorectal surgery; prophylactic antibiotics stopped after incision closure. Overnight he developed a temperature of 38.6 C with heart rate 102/min; BP is 124/76 mm Hg and lactate 1.4 mmol/L. Yesterday afternoon the incision was intact and dry; it now has purulent yellow drainage saturating the dressing, erythema extending 5 cm with increasing incisional tenderness, and two loose staples at the draining area without a gap through deeper layers. The abdomen is soft without rigidity or crepitus. He is alert, tolerating a diet, and ambulating with assistance. WBC has risen from 9.2 to 16.8 x 10^9/L with neutrophilia, and glucose is 246 mg/dL. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Anastomotic leak with peritonitis
Septic shock from an abdominal source
Fascial wound dehiscence
Incisional surgical site infection

Actions to take

Select 2
Prepare the client for emergency exploratory laparotomy
Notify the surgeon for incision evaluation
Give a 30 mL/kg crystalloid bolus over 3 hours
Swab the old dressing surface for a culture
Collect an aseptic wound specimen during drainage

Parameters to monitor

Select 2
Temperature and heart rate
Abdominal rigidity and rebound tenderness
Erythema edge versus the marked line
Mean arterial pressure every 15 minutes
Serum albumin level

## Explanation

Purulent drainage, 5 cm of spreading erythema, tenderness, fever, tachycardia, and a WBC rise on postoperative day 5 indicate an incisional surgical site infection. A soft abdomen argues against a leak, and normal BP and lactate argue against septic shock. The surgeon is notified for opening and drainage, and an aseptic wound specimen is taken during drainage; temperature, heart rate, and the erythema border show the response.

## In-depth explanation

Quick answer
Condition: incisional surgical site infection. Actions: notify the surgeon for incision evaluation (opening and drainage), and collect an aseptic wound specimen during drainage. Monitor: temperature and heart rate, and the erythema edge versus the marked line.

Why this is correct
Surgical site infections typically appear 4 to 7 days after surgery. Purulent drainage from the incision is the defining sign, and spreading erythema with tenderness confirms it; fever and a WBC of 16.8 show a systemic response. Source control (opening and draining the incision) is the main treatment, and the best culture comes from deep tissue or pus collected aseptically at that time. Marking the erythema edge and trending temperature and heart rate show whether the infection is receding after drainage and antibiotics.

Easy analogy or mental picture
An infected incision is a pimple that has to be opened: antibiotics help, but relief comes when the pus drains. Drawing a line around the redness is how you see whether the fire is shrinking.

Memory hook
Pus + spreading red + POD 4 to 7 = open it, culture the pus, draw the line.

NCLEX decision rule
Identify the depth of an infection from the data (incision versus abdomen) and choose source control first; monitor the local border and systemic signs that reflect that specific infection.

Why the other choices are wrong
An anastomotic leak shares fever and leukocytosis, but the abdomen is soft without rigidity, so emergency laparotomy and checks for rigidity follow the wrong problem. Septic shock is excluded by a BP of 124/76 and lactate of 1.4; a 30 mL/kg bolus and 15-minute MAP checks are for hypoperfusion he does not have. Fascial dehiscence is tempting because staples are loose, but there is no gap through deeper layers and the drainage is purulent, not serosanguineous. A swab of an old dressing surface grows skin contaminants and misleads therapy. Serum albumin reflects nutrition and healing, not the infection's response to treatment.

References
1CDC NHSN — Surgical Site Infection Event ProtocolCriteria for superficial incisional SSI, including purulent drainage and incision opened by the surgeon
2Society of Critical Care Medicine — Surviving Sepsis CampaignHypoperfusion criteria such as hypotension and lactate that separate septic shock

## Clinical scenario

Case update
Postoperative day 5: purulent incisional drainage, spreading erythema, fever, tachycardia, and leukocytosis with a soft abdomen and normal lactate.

## Key concepts

- **Surgical site infection** — Infection of the incision or deeper tissues within 30 days after surgery, classified as superficial, deep, or organ-space.
- **Source control** — Physical removal of the infection focus, such as opening and draining an infected incision.
- **Anastomotic leak** — Leakage from a surgical bowel connection, usually causing peritoneal signs such as rigidity.

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