A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site.

Drainage from the surgical site is 30 mL less than yesterday.

The patient reports adequate pain control with medications.

Urine is clear yellow and urine output is greater than 40 mL/hr

Answer and Explanation

The Correct Answer is A

A. There is no redness, warmth, or drainage at the insertion site.

This assessment is crucial for evaluating the status of the abdominal drain site. The absence of redness, warmth, or drainage suggests that the insertion site is healing well without signs of infection or inflammation. It indicates that the drain is functioning properly and that there are no immediate complications related to the drain insertion. This assessment directly addresses the goals related to monitoring the drain site for signs of infection or dysfunction.

B. Drainage from the surgical site is 30 mL less than yesterday.

Monitoring the drainage output from the surgical site is important to assess for changes in drainage patterns. A decrease in drainage volume may indicate reduced fluid accumulation at the surgical site, potentially reflecting improved healing and decreased need for drainage. However, while this assessment is valuable, it is not as directly related to assessing the status of the drain itself or evaluating complications at the insertion site as option A.

C. The patient reports adequate pain control with medications.

Pain control is an essential aspect of postoperative care, but it is not specifically related to assessing the functionality or complications of the abdominal drain. While pain management is important for patient comfort and recovery, it does not directly address the goals related to monitoring the drain site for signs of infection, leakage, or other complications.

D. Urine is clear yellow, and urine output is greater than 40 mL/hr.

While monitoring urine output and characteristics is important for assessing renal function and hydration status, it is not directly related to assessing the abdominal drain or its complications. Clear yellow urine and adequate urine output are generally positive indicators but do not provide specific information about the functionality or status of the drain.

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Correct Answer is B

Explanation

A. Infection: While infection can certainly delay wound healing and contribute to the development of chronic wounds, it is more of a local factor rather than a systemic cause. Infections can hinder the normal healing process and lead to tissue damage, inflammation, and prolonged wound healing.

B. Malnutrition

A chronic wound is a wound that fails to progress through the normal stages of healing in an orderly and timely manner. Systemic factors can significantly impact wound healing, and malnutrition is one such systemic cause. Malnutrition, which refers to an inadequate intake or absorption of nutrients essential for healing, can impair the body's ability to repair tissues, fight infection, and generate new cells.

C. Continued pressure: Prolonged pressure, such as that experienced in pressure ulcers, can lead to tissue ischemia (lack of blood flow) and tissue necrosis, resulting in chronic wounds. However, this is considered a local factor related to the specific site of the wound and pressure-related damage.

D. Venous insufficiency: Venous insufficiency can cause chronic wounds, particularly venous ulcers, due to impaired venous return leading to increased pressure in the veins of the lower extremities. This pressure can result in tissue damage and poor wound healing. While venous insufficiency is a systemic condition, it primarily affects specific areas of the body (such as the lower legs) and is more directly related to the development of localized chronic wounds in those areas.

A. Body mass index (BMI) of 19 B. History of deep vein thrombosis C. Aged 55 years old D. Type 2 diabetes mellitus

Correct Answer is D

Explanation

A. Body mass index (BMI) of 19:

A BMI of 19 falls within the normal weight range. While obesity (high BMI) is a known risk factor for surgical complications, including SSIs, having a lower BMI (underweight) like 19 may not directly increase the risk of SSIs. However, extreme malnutrition or low BMI due to underlying health conditions could potentially impact wound healing and immune function, indirectly contributing to infection risk.

B. History of deep vein thrombosis (DVT):

A history of deep vein thrombosis is a risk factor for surgical complications, including SSIs. Patients with a history of DVT may have impaired circulation or underlying vascular issues, which can affect tissue perfusion, wound healing, and increase the risk of infections.

C. Aged 55 years old:

Age is a risk factor for surgical complications, including SSIs. Older adults, typically defined as those aged 65 and above, may have reduced immune function, slower wound healing, and underlying health conditions that contribute to infection risk. While 55 years old is not considered advanced age in terms of surgical risk, older age in general is associated with a higher risk of complications.

D. Type 2 diabetes mellitus:

Type 2 diabetes mellitus is a significant risk factor for SSIs. Diabetes can impair immune function, delay wound healing, and increase susceptibility to infections. Poorly controlled blood sugar levels in diabetic patients can further exacerbate the risk of SSIs post-surgery.

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A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

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