The nurse instructs the client to care for an open, draining wound before discharge. Which does the nurse include in client teaching for wound healing by secondary intention? (Choose all that apply.)

Question

1. Avoid bathing and showers until directed.
2. Take your temperature at least once every day.
3. Report any drainage and redness of wound bed.
4. Change the dressing at the first sign of drainage.
5. Eat a well-balanced diet with high-quality protein.
6. Palpate the wound edges for a healing ridge daily.

Answer 1

1, 2, 5
1. Baths and showers are avoided without provider approval depending on the amount of healing and the status of the wound. If the wound is draining large amounts and the tissue has not granu-lated, baths and showers are contraindicated to prevent exposure to microorganism and cross-contamination from other regions of the body.
2. The client needs to take a body temperature at least once a day for early detection of infection. Not every fever the client has will be an infection, but the client reports all fevers and allows the surgical team to determine the presence of infection.
5. Wound healing depends on a well-balanced diet with high-quality protein to provide the ne-cessary substrate for tissue repair and normal cellular function. This is especially true for the client with a wound healing by secondary intention with wound drainage because the client loses more protein through wound exudate than a closed wound loses.
3. The nurse instructs the client to expect wound drainage because a properly healing wound by secondary intention can drain for a long time. The nurse also instructs the client that an expected outcome of the wound care plan is granulation tissue formation in the wound bed; therefore, a draining wound and a reddened wound bed are desirable and the client does not need to report these findings. The client needs to report any change in the drainage, other than a decrease in volume, however, and redness at the wound edges.
4. Dressing changes are a regularly scheduled routine, usually, and are an integral part of the healing process; however, if the client changes the dressing at the first sign of drainage, the client will perform an excessive number of dressing changes daily that can result in skin damage. In-stead, the nurse instructs the client to change the dressing when it becomes saturated and before it begins to leak.
6. Healing by secondary intention does not heal with a healing ridge because it heals from the inside out or the bottom up. The healing ridge forms in wounds healing by primary intention.