A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?
A.
A client who has swelling and tenderness around the wound
B.
A client who has brown crusting over the wound
C.
A client who has serosanguineous drainage from the wound
D.
A client who has urticaria and itching around the wound
The Correct Answer and Explanation is:
The correct answer is A. A client who has swelling and tenderness around the wound.
Explanation:
When assessing wounds, recognizing signs of infection is crucial for timely intervention and treatment. Each option provides a different manifestation related to wound assessment, and understanding these can help in differentiating between normal wound healing processes and potential infections.
A. A client who has swelling and tenderness around the wound: Swelling (edema) and tenderness around a wound are classic signs of infection. Infection often leads to localized inflammation, which is characterized by increased blood flow to the area. This inflammation manifests as swelling and tenderness, accompanied by redness (erythema) and heat (increased temperature). The presence of these symptoms suggests that the body’s immune system is responding to a potential infection, which might be caused by bacteria or other pathogens. This client needs further evaluation and possibly antibiotic treatment to manage the infection effectively.
B. A client who has brown crusting over the wound: Brown crusting over a wound is often indicative of dried blood or serum, which can occur during the healing process. This finding alone is not typically a sign of infection but rather a normal part of wound healing, particularly if the crusting is not associated with other symptoms of infection, such as increased redness or swelling.
C. A client who has serosanguineous drainage from the wound: Serosanguineous drainage, which is a mix of serum and blood, is common in the early stages of wound healing. It is not unusual for wounds to produce this type of drainage as they heal. While the presence of drainage should be monitored, serosanguineous fluid alone does not necessarily indicate infection unless accompanied by other signs like increased redness, swelling, or a foul odor.
D. A client who has urticaria and itching around the wound: Urticaria (hives) and itching are often signs of an allergic reaction rather than an infection. This could be related to a reaction to dressings, medications, or other substances rather than a direct infection of the wound itself. While itching and urticaria are important to address, they do not specifically point to a wound infection.
In summary, swelling and tenderness (Option A) are strong indicators of a potential wound infection and should prompt further assessment and possible intervention.