Chapter 48, Problem 1CAQ

Summary Introduction

To discuss:

The critical assessment that should be made when dressing is removed, when the physician observed a foul-smelling tan-colored drainage from Mrs. S’s hi incision and orders dressing 3 times a day with saline gauze.

Case summary:

Mrs. S is a 76-year-old patient who had undergone surgery for hip replacement and 7 days on postoperative. Mrs. S had developed foul-smelling tan-colored drainage with redness from the hip incision. She has a medical history of mild hypertension and osteoarthritis and her stay in the hospital is prolonged due to a blood clot in her lower-extremity. Due to hip incision, she is unable to turn or transfer from bed to chair. On the postoperative day of 7, she complains burning sensation and pain in her lower extremity and in the sacral region. Mrs. S is continent of stool and urine.      

Explanation of Solution

When the dressing is removed, the nurse should assess the dressing gauze for the amount of drainage or any red-colored gauze, or any presence of foul-smell. Based on the color of the gauze the nurse can make an assessment of whether the incision still contains the oozing of dead cells.   

Conclusion

The dressing gauze can state different stages of the wound, the tan-colored gauze states presence of infection or dead cells or tissue damage causing the redness.