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Client will consume adequate nutrition to meet nutritional requirements within 1 week: Adequate nutrition supports wound healing by providing essential proteins, vitamins, and minerals. However, this goal addresses the nutritional status of the client rather than directly targeting impaired physical mobility.

Client will report pain management strategies and reduce pain to a tolerable level: Managing pain is crucial for overall comfort and participation in care, but this goal relates primarily to pain control rather than addressing the mobility deficits identified in the nursing diagnosis of impaired physical mobility.

Client will remain free of wound infections during the hospitalization: Preventing infection is an important outcome for overall wound management, but it does not specifically target the client’s physical mobility. While infection prevention supports healing, it does not measure improvement in the client’s ability to perform or assist with movement.

Sterile gloves should always be used for dressing changes performed in the hospital setting: While sterile technique is critical for certain wounds, it is not required for every dressing change in the hospital. Using sterile gloves for all dressings would be unnecessary, resource-intensive, and not aligned with standard infection control guidelines.

Sterile gloves should always be used for dressing changes performed by nurses: The role of the nurse does not automatically dictate the need for sterile gloves. The choice of clean versus sterile technique depends on the wound’s characteristics, depth, contamination level, and the presence of devices like drains or surgical sutures.

Surgical wound: Surgical wounds, particularly fresh postoperative incisions, require sterile technique to minimize the risk of introducing pathogens. Sterile gloves, sterile dressings, and aseptic technique are used to protect the wound from infection during dressing changes until healing is well established.

Put pressure on the wound with a sterile gauze pad: Applying pressure to a wound with eviscerated abdominal organs can cause additional trauma to the exposed viscera and may compromise blood flow to the protruding tissues. Pressure could also increase the risk of tissue injury and worsen the surgical emergency.

Cover the wound with a sterile gauze pad: Although covering the wound with sterile gauze helps protect the exposed tissues from contamination, dry gauze can cause the exposed organs to dry out. Desiccation of abdominal organs can lead to tissue damage and impaired viability. Maintaining moisture of the exposed viscera is essential to preserve tissue integrity.

Cover the wound with a transparent dressing: Transparent dressings are designed for superficial wounds or sites requiring visualization, such as intravenous insertion sites. They are not appropriate for managing evisceration because they do not provide adequate moisture or protection for exposed internal organs.

During the first 24 to 48 hours after injury: The first 24 to 48 hours after an injury usually correspond to the normal inflammatory phase of wound healing as part of the body’s natural response to tissue damage and increased blood flow. These early changes are not indicative of infection because bacterial growth and immune response require more time

Up to 5 days after injury: Although infection can still be recognized around this time if it was previously unnoticed, most contaminated wounds begin to show clinical signs earlier, usually by the second or third day. Waiting until five days for initial signs would be less typical, as bacterial colonization and inflammatory responses generally manifest sooner in susceptible wounds.

Five to seven days after injury: Signs of infection appearing this late are less common as an initial presentation in traumatic or contaminated wounds. By this stage, either healing has progressed normally or infection would typically have been detected earlier through symptoms such as increasing pain, erythema, warmth, and purulent drainage.

Client reporting, "My incision is hurting.": Pain at the incision site is a common postoperative finding, especially in the early stages of wound healing after major surgery such as a total abdominal hysterectomy. Tissue trauma during surgery activates inflammatory mediators that stimulate nociceptors, leading to localized discomfort.

Approximation of the incision edges has occurred: Proper approximation of wound edges is an expected and desirable sign of normal wound healing. Surgical closure techniques such as sutures, staples, or adhesive strips are intended to bring tissue layers together to promote primary intention healing. This indicates that the wound is stable and tissue repair processes is effective.

Client asks, "Why has my incision started to itch?": Itching at a healing incision is commonly associated with the proliferative phase of wound healing, during which epithelial cells regenerate and nerve endings begin to recover. Histamine release and the formation of new tissue can stimulate sensory nerves, leading to itching.

By keeping the drain lower than the insertion site: Positioning the drain below the level of the insertion site helps promote gravity-assisted drainage and prevents backflow of fluid toward the wound. While this positioning supports effective drainage, it does not generate negative pressure required for the device to function. Closed suction drains rely on a vacuum not gravity alone.

By turning the suction on: Jackson-Pratt and Hemovac drains are closed suction systems that generate their own negative pressure within the collection reservoir. They are not connected to wall suction or external suction devices. Therefore, there is no suction switch to activate; the vacuum must be manually recreated after the reservoir has been emptied.

By "milking" the tubing: Milking the tubing refers to gently squeezing and sliding along the drainage tubing to move clots or thick drainage toward the reservoir. Although this may help maintain patency of the tubing, it does not generate the negative pressure necessary for the suction system to function. The vacuum must still be recreated by compressing the reservoir.