The nurse is caring for a patient one week post-surgery.
Which finding should the nurse expect to see if the surgical incision is healing properly?
A.
Eschar and slough in the wound.
B.
Beety red granulation tissue.
C.
Erythema and serosanguineous drainage.
D.
A well-approximated incision.
The correct answer and Explanation is :
The correct answer is D. A well-approximated incision.
Explanation:
One week post-surgery, the primary indicators of proper incision healing are generally assessed based on the appearance and condition of the wound. Here’s why option D is the best choice:
- Well-Approximated Incision:
- Definition: A well-approximated incision means that the edges of the surgical wound are neatly aligned and have come together properly. This is a good sign that the healing process is on track. The wound margins should be touching each other, and there should be minimal separation or gaping.
- Healing Indicators: At one week, the incision should show signs of early healing. Sutures or staples may still be in place, but the area should appear tidy without significant separation. This is a positive indication that the body’s healing mechanisms are effectively working to close the wound and reduce the risk of complications like dehiscence (wound reopening).
- Alternative Findings:
- Eschar and Slough (Option A): These are types of necrotic tissue. Eschar is a dry, black or brown crust that can form over a wound, while slough is a yellow or white, dead tissue that can be stringy or sticky. Their presence usually indicates a wound that is not healing properly and may be at risk of infection or chronicity.
- Beet-red Granulation Tissue (Option B): Granulation tissue is healthy tissue that appears red or pink and is usually a positive sign of wound healing. However, the description “beet-red” might be too vivid for this stage. Healthy granulation tissue is typically more pinkish-red and indicates that new tissue is forming, but it’s just one aspect of the healing process.
- Erythema and Serosanguineous Drainage (Option C): Erythema (redness) and serosanguineous drainage (a mix of serum and blood) can be normal post-surgery but might also indicate inflammation or a potential problem if excessive. One week post-surgery, some erythema and minimal drainage can be normal, but pronounced redness or excessive drainage might suggest complications like infection.
In summary, a well-approximated incision is a key indicator of proper healing at one week post-surgery, signifying that the wound is closing as expected and that the healing process is progressing well.