A client with fair skin, who is an avid runner, is diagnosed with malignant melanoma, located on the lateral surface of the lower leg. After a wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic?

Heart rate 88 beats/minute: This is within the normal range (60-100 bpm) and does not require immediate intervention.

Blood pressure 122/72 mm Hg: This is within a normal range and does not indicate an urgent issue.

Temperature 100.5°F (38°C): An elevated temperature suggests a possible infection, such as cellulitis or deep vein thrombosis (DVT), which requires further evaluation.

Reports of pain with ambulation: Pain with walking, especially in a client with peripheral vascular disease and diabetes, may indicate worsening circulation, infection, or DVT.

Respirations 20 breaths/minute: This is within the normal range (12-20 breaths/minute) and does not require immediate intervention.

Left lower leg with erythema, warm, and swollen: These are signs of inflammation or infection, such as cellulitis or a possible DVT, both of which require urgent medical attention.

Blood glucose 252 mg/dL (13.9 mmol/L): Elevated blood glucose can impair wound healing, increase the risk of infection, and contribute to further complications in a client with diabetes.

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.