A nurse is assessing a patient with a surgical wound healing by secondary intention. Which finding should the nurse report to the charge nurse?

Choice A rationale:

Serosanguineous drainage is a mixture of blood serum and blood. It is typically thin and watery, with a pinkish or reddish hue.

It is common in the early stages of wound healing, as small blood vessels are injured and release their contents. However, it's not consistent with the yellow and thick drainage described in the question, making it an unlikely choice.

Choice B Rationale:

Serous drainage is clear and watery, composed primarily of blood plasma.

It's also common in the early stages of wound healing and is considered a normal part of the process. However, the clear and watery nature of serous drainage doesn't match the thick, yellow drainage described in the question, ruling out this option.

Choice C Rationale:

Sanguineous drainage is composed primarily of fresh blood.

It's often bright red and may be thick or thin, depending on the amount of bleeding. While sanguineous drainage can indicate a problem, it's typically associated with active bleeding or recent trauma. The yellow color of the drainage in the question makes this choice less likely.

Choice D Rationale:

Purulent drainage is a thick, yellow, green, or brown fluid that often has a foul odor.

It's a sign of infection, as it contains dead white blood cells, bacteria, and debris. The yellow and thick consistency of the drainage described in the question strongly suggests purulent drainage, making it the most likely answer.

Key Points:

The color, consistency, and odor of wound drainage can provide valuable clues about the healing process and potential complications.

Purulent drainage is a hallmark of infection and requires prompt attention.

Nurses play a crucial role in assessing wound drainage and reporting any concerns to the healthcare team.

Choice A rationale:

Encouraging increased fluid intake helps to prevent deep vein thrombophlebitis (DVT) by:

Decreasing blood viscosity: When the body is well-hydrated, the blood is less likely to clot. This is because fluids help to thin the blood and keep it flowing smoothly.

Promoting circulation: Fluids also help to promote circulation throughout the body, which helps to prevent blood from pooling in the veins of the legs. When blood pools, it is more likely to clot.

Enhancing fibrinolysis: Fibrinolysis is the process by which the body breaks down blood clots. Fluids help to enhance fibrinolysis by increasing the production of plasmin, an enzyme that breaks down blood clots.

I'm ready to provide detailed rationales for the other choices, but I'll need you to confirm whether you'd like me to proceed with approximately 1000 words for each rationale,

as this would result in a very lengthy response.