A nurse is caring for a patient receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm.
What action should the nurse take first?

Choice A rationale:

Irrigating the tubing with sterile normal saline solution is not a routine part of closed-wound drainage system care.

It's usually only done if there's evidence of a blockage or infection, and only under the direction of a healthcare provider. Unnecessary irrigation could introduce bacteria into the system and increase the risk of infection.

It could also disrupt the delicate balance of fluids in the wound and delay healing.

Choice B rationale:

Replacing the drainage plug after releasing hand pressure on the device is not correct. The drainage plug should actually be replaced before releasing hand pressure.

This is to prevent air from entering the system, which could disrupt the vacuum and impair drainage.

Choice D rationale:

Emptying the reservoir once per day is not frequent enough.

The reservoir should be emptied whenever it becomes full, which could be more often than once a day, depending on the amount of drainage.

Allowing the reservoir to become too full could put pressure on the wound and impede healing.

Choice C rationale:

Fully re-collapsing the reservoir after emptying it is essential to maintain the vacuum that promotes drainage. If the reservoir is not fully re-collapsed, the vacuum will be lost, and drainage will slow or stop.

This could lead to fluid accumulation in the wound, which could increase the risk of infection and delay healing.

Choice A rationale:

Serosanguineous drainage is a mixture of blood serum and blood. It is typically thin and watery, with a pinkish or reddish hue.

It is common in the early stages of wound healing, as small blood vessels are injured and release their contents. However, it's not consistent with the yellow and thick drainage described in the question, making it an unlikely choice.

Choice B Rationale:

Serous drainage is clear and watery, composed primarily of blood plasma.

It's also common in the early stages of wound healing and is considered a normal part of the process. However, the clear and watery nature of serous drainage doesn't match the thick, yellow drainage described in the question, ruling out this option.

Choice C Rationale:

Sanguineous drainage is composed primarily of fresh blood.

It's often bright red and may be thick or thin, depending on the amount of bleeding. While sanguineous drainage can indicate a problem, it's typically associated with active bleeding or recent trauma. The yellow color of the drainage in the question makes this choice less likely.

Choice D Rationale:

Purulent drainage is a thick, yellow, green, or brown fluid that often has a foul odor.

It's a sign of infection, as it contains dead white blood cells, bacteria, and debris. The yellow and thick consistency of the drainage described in the question strongly suggests purulent drainage, making it the most likely answer.

Key Points:

The color, consistency, and odor of wound drainage can provide valuable clues about the healing process and potential complications.

Purulent drainage is a hallmark of infection and requires prompt attention.

Nurses play a crucial role in assessing wound drainage and reporting any concerns to the healthcare team.