The nurse assesses the patient's postoperative wound and determines that the wound is inflamed, most likely because of an infection, when noting what classic symptoms? (Select all that apply.)
A) Heat around the site of the wound
B) Redness around the site of the wound
C) Increase in reports of pain
D) Edema at the site of the wound
E) Serosanguineous drainage from the wound
A, B, C, D
Feedback:
Activation of the inflammatory response produces a characteristic clinical picture. Heat occurs because of the increased blood flow to the area. Swelling occurs because of the fluid that leaks into the tissues as a result of the change in capillary permeability. Redness is related to the increase in blood flow caused by the vasodilation. Pain comes from the activation of pain fibers by histamine and the kinin system.
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