Which step should the nurse take next?
While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance.
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A. Notify the physician that the wound may be dehiscing. B. Apply normal saline solution to keep the wound moist. C. Do nothing because this is granulation tissue. D. Prepare the client for debridement of the suture line.
The answer to this is letter C. The nurse should not do anything that may complicate matters. The granulation tissue is in its healing process. This means that the wound is healing nicely and should not be given too much attention. The only time when nurses should pay attention to this when it shows necrotic tissue.
It should also be a concern for nurses when they see that the wound is open. There are some wounds that need to be kept moist in order to heal nicely while there are some that are required to stay dry up to a certain period of time. In this case, the wound should not be given too much attention.
Do nothing because this is granulation tissue.-rationale: during the fibrinoplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. this normal occurrence requires no further action. there is no evidence of wound dehiscence or necrotic tissue. there is also no indication that the wound is open or needs to be kept moist.client needs category: physiological integrityclient needs subcategory: basic care and comfortcognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 1190.