The nurse is assessing a patient's postoperative wound and finds it has separated from the suture line with extrusion of the intestine through the opening. How does the nurse document this finding?

Pin site care is essential to prevent infections and other complications associated with external fixation devices. The nurse should instruct the patient to clean the pin insertion sites daily with a sterile saline solution or as per healthcare provider's instructions. The patient should also observe for signs of infection, such as redness, swelling, warmth, and drainage, and report any concerns to the healthcare provider.

Assessing the skin under the foam boot twice daily is not specific to external fixation devices, and it may not be relevant to this patient's care plan. The nurse should focus on teaching the patient about external fixation device care specifically.

Taking prophylactic antibiotics before any dental work for the rest of your life is not relevant to external fixation devices or right lower leg fractures. It is a recommendation for patients with certain heart conditions who may be at risk of developing infective endocarditis during dental procedures.

Removing the external fixator for the shower is not recommended as the device should be kept dry to prevent infections. The nurse should instruct the patient to cover the device with a waterproof dressing or plastic bag during showering to protect it from getting wet.

Acute renal failure is characterized by a sudden decline in kidney function, resulting in the inability of the kidneys to adequately filter waste products and maintain fluid and electrolyte balance. Monitoring urine output is essential in assessing kidney function and determining the severity of renal failure. A decrease in urine output or anuria may indicate worsening renal function and the need for immediate interventions.

Assessing electrolyte levels, such as sodium, potassium, calcium, and phosphorus, is crucial because renal failure can disrupt the balance of these electrolytes in the body. Imbalances can lead to complications such as electrolyte abnormalities, cardiac dysrhythmias, and neuromuscular disturbances. Prompt identification and management of electrolyte imbalances are essential in preventing further complications and supporting optimal patient outcomes.