Spreading redness, purulent or foul drainage, fever, and increasing pain indicate infection; report and obtain a culture.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse is providing pin site care for a client in skeletal traction. Which observation at a pin site should the nurse report as a sign of infection?
Answer: B. Purulent (yellow or green) drainage, increasing redness, warmth, and tenderness around a pin site indicate infection and must be reported. A small amount of clear serous drainage, intact surrounding skin, and a pin that is firmly seated are expected and not signs of infection.
Question 2 of 5
A surgical client is at risk for a surgical site infection. Which evidence-based action helps prevent this complication?
Answer: B. Maintaining normothermia (preventing intraoperative and postoperative hypothermia) and good glycemic control are evidence-based measures that reduce surgical site infection risk. Hair, if removed, should be clipped (not shaved) and only when necessary.
Question 3 of 5
A client is in balanced suspension skeletal traction with a Steinmann pin. Which finding at the pin site requires the nurse to notify the provider?
Answer: B. Purulent drainage, increasing redness, and warmth at the pin site suggest infection or osteomyelitis and must be reported. A small amount of clear or serous crust at the insertion site is expected and does not require notification.
Question 4 of 5
A nurse is changing a postoperative dressing. Which technique best prevents surgical site infection?
Answer: A. Using sterile technique when performing a dressing change on a surgical wound prevents introduction of microorganisms and reduces the risk of surgical site infection. Hand hygiene before and after, along with sterile supplies and proper disposal, are essential.
Question 5 of 5
A nurse is assessing a client for signs of a localized wound infection. Which finding is most indicative of infection?
Answer: B. Purulent (pus-like) drainage from a wound, along with increasing redness, warmth, and tenderness, indicates a localized infection. Clear serous drainage and well-approximated edges are expected findings.
Keep the streak going with more questions like these, each with a full rationale.
What is surgical site infection?
It causes pain, delayed healing, prolonged hospitalization, and sepsis risk. Common organisms include Staphylococcus aureus (including MRSA). Prevention centers on sterile technique, timely prophylactic antibiotics, glucose control, normothermia, and proper wound care.
Key points to remember
- Local signs include increasing incisional pain, redness, warmth, swelling, purulent drainage, and wound edge separation.
- Systemic signs include fever (often appearing after the first 48-72 postoperative hours), chills, and rising WBC count.
- Major risk factors include diabetes/hyperglycemia, obesity, smoking, immunosuppression, poor nutrition, and prolonged surgery.
- Prophylactic antibiotics are most effective when given within 60 minutes before incision and stopped within 24 hours.
- Hyperglycemia, hypothermia, and inadequate tissue oxygenation all impair healing and raise infection risk.
- Hand hygiene and sterile technique during dressing changes are the most important prevention measures.
Signs & symptoms
- Redness, warmth, purulent drainage
- Fever > 38°C, ↑WBC
- Usually 3–7 days post-op
Nursing priorities
- Perform hand hygiene and use strict sterile technique for all dressing changes and wound care.
- Assess the incision each shift for redness, warmth, swelling, drainage, odor, and approximation, and monitor temperature and WBC.
- Maintain tight glucose control, adequate nutrition (protein, vitamin C, zinc), hydration, and normothermia to support healing.
- Administer prophylactic and treatment antibiotics on time; obtain wound cultures before starting antibiotics when infection is suspected.
- Educate the patient on incision care and hand hygiene, and ensure proper drain management to prevent fluid collection.
Labs & values
Patient teaching
- Wash hands before and after touching the incision and keep the wound clean and dry as instructed.
- Report increasing redness, swelling, warmth, drainage, foul odor, fever, or increased pain.
- Eat a protein- and vitamin-C-rich diet, stop smoking, and keep blood sugar controlled to promote healing.
Red flags: report now
- Spreading redness, purulent or foul drainage, fever, and increasing pain indicate infection; report and obtain a culture.
- Wound dehiscence (separation) or evisceration (organs protruding) is a surgical emergency; cover with sterile saline-moistened gauze and keep the patient supine with knees bent while notifying the surgeon.
- High fever, hypotension, tachycardia, and confusion suggest progression to sepsis; escalate immediately.
- Never apply a soiled or non-sterile dressing or break sterile technique during wound care.
References
Clinical references for this topic
