A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. Which is the greatest clinical risk related to this situation?

Potential Conditions

Wound healing by secondary intention (Correct): This occurs when the wound is left open to heal from the inside out due to extensive tissue loss, high infection risk, or inability to approximate wound edges. The client’s wound is large, packed with gauze, and not sutured, indicating it is healing by secondary intention.

Wound healing by primary intention (Incorrect): Primary intention healing occurs when wound edges are surgically approximated with sutures or staples, allowing faster healing with minimal scarring. Since the client’s wound is open and packed, this is not the correct choice.

Actions to Take

Use sterile procedure to change dressing (Correct): Using sterile technique reduces the risk of infection and promotes wound healing, which is crucial for open wounds healing by secondary intention.

Encourage the client to consume a balanced diet (Correct): Proper nutrition, especially with protein, vitamin C, and zinc, enhances wound healing by supporting tissue regeneration and immune function.

Culture the wound (Incorrect): A wound culture is only necessary if there are signs of infection, such as increased drainage, foul odor, or worsening erythema. Since there is no mention of infection in the scenario, culturing the wound is not an immediate action.

Parameters to Monitor

Drainage on the dressing (Correct): Monitoring drainage helps assess healing progress and detect infection. An increase in purulent, foul-smelling, or discolored drainage may indicate complications.

The formation of granulation tissue (Correct): Granulation tissue, which is pink and bumpy, indicates healthy wound healing. Lack of granulation tissue suggests delayed healing.

Blood pressure (Incorrect): While blood pressure monitoring is important for overall health, it does not directly indicate wound healing progress.

Intake and output (Incorrect): Although hydration is important for healing, tracking intake and output is more relevant for clients at risk of fluid imbalances rather than wound healing assessment.

A. Enzyme immunoassay. The enzyme immunoassay (EIA), also known as the ELISA test, is used as a primary screening test for HIV. If the EIA test is positive, a confirmatory test, such as the Western Blot, is performed to ensure accuracy.

B. Western Blot. The Western Blot is a confirmatory test for HIV used to verify positive results from an initial screening test. It detects specific HIV antibodies and is highly specific, reducing the likelihood of false positives.

C. White blood cell differential. A white blood cell (WBC) differential assesses the overall immune response but does not diagnose HIV. While some HIV patients may show low WBC counts, this test is not specific for HIV infection.

D. CD4+ cell count. CD4+ cell count is used to monitor disease progression and immune function in HIV-positive patients, but it is not a confirmatory test for diagnosing HIV. A low CD4+ count suggests HIV progression toward AIDS rather than initial diagnosis.