Final answer:
The nurse should document the wound's condition, notify the physician for assessment, and cover the wound with sterile dressing. Watching for redness, swelling, and pain is critical to spot infection, and a team approach to patient care is essential. Prompt laboratory analysis of purulent discharge can identify bacteria and refine treatment.
Step-by-step explanation:
When a nurse observes that the wound edges have begun to pull apart 2 hours after removing the surgical staples, immediate action is required to prevent worsening of the condition, which could lead to a dehiscence or potential infection. The nurse should document the current state of the wound, including its measurement and appearance, and then promptly notify the physician to assess the wound and determine the appropriate intervention, which may include re-suturing the wound or providing additional wound care and support. In the meantime, the nurse may cover the wound with a sterile dressing to protect it from contamination and to support the surrounding tissue.
It is important to watch for increased redness, swelling, and pain after a wound has been treated because these symptoms may indicate an infection. Healthcare providers, including surgeons, nurses, and anesthesia professionals, should review aloud the key concerns for the recovery and care of the patient. This collaborative approach ensures that the patient receives the best possible care and that any signs of complications are addressed promptly.
In case of signs of infection, such as purulent discharge, it is crucial to obtain a sample and send it for laboratory analysis to identify the causative organisms. This can guide targeted antibiotic treatment and prevent further complications. The patient should be instructed to keep the wound clean and apply prescribed topical antibiotics as advised by the healthcare provider.