A nurse is evaluating a postoperative patient and notes a moderate amount of serous drainage on the dressing 24 hours after surgery. Which of the following is the appropriate nursing action?
A. Notify the surgeon about evidence of infection immediately.
B. Leave the dressing intact to avoid disturbing the wound site.
C. Remove the dressing and leave the wound site open to air.
D. Change the dressing and document the clean appearance of the wound site.
Correct Answer: D. Change the dressing and document the clean appearance of the wound site.
A moderate amount of serous drainage from a recent surgical site is a sign of normal healing. Serous drainage is clear, thin, and watery. The production of serous drainage is a typical response from the body during the normal inflammatory healing stage.
Option A: Purulent drainage would indicate the presence of infection. Purulent drainage is milky, typically thicker in consistency, and can be gray, green, or yellow in appearance. If the fluid becomes very thick, this can be a sign of infection. Yet, if there is a large amount of serous drainage, it can be the result of a high bioburden count.
Option B: A soiled dressing should be changed to avoid bacterial growth and to examine the appearance of the wound. Overall, it should be noted that the dressing selection should be based on the individual patient and wound characteristics. If the wound is not in the normal inflammatory phase of healing, the clinician must investigate what is the root cause and how to manage the drainage.
Option C: The surgical site is typically covered by gauze dressings for a minimum of 48-72 hours to ensure that initial healing has begun. Changing the dressing less allows the wound bed to be left undisturbed, which allows for the migration of new cells. When wound beds are left undisturbed in an optimal moist environment, they are able to heal at a faster rate.