Maternal & Newborn Nursing
A 26 year old patient in the gynecology ward complained of pain and swelling in episiotomy stitches on her…
A 26 year old patient in the gynecology ward complained of pain and swelling in episiotomy stitches on her second post natal day. On examination, the localized swelling, redness, foul smell and pussy discharge were identified at the stitches site after examination, the nurse checked her vital signs BP 116/58 RR 28 HR 132 TEM 39.8 Which of the following should the nurse do prior patient examination by the gynecologist?
Explanation
Core Concept: When examining the perineal area, especially in the presence of an infected episiotomy, maintaining patient privacy and dignity is a fundamental nursing and ethical priority. The nurse must ensure the environment is secure and the patient is properly draped before any physical assessment or intervention.
Clinical Presentation:
- Localized perineal pain, erythema, edema, and purulent, foul-smelling discharge.
- Systemic signs of infection: high fever (39.8°C), tachycardia (132 bpm), and tachypnea (28 breaths/min).
- Risk of wound dehiscence and systemic sepsis.
Diagnosis:
- First-line diagnostic plan: Visual inspection of the episiotomy site using the REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation).
- Most accurate (gold standard) test: Wound swab culture and sensitivity, along with complete blood count (CBC) and blood cultures if sepsis is suspected.
Management:
- Acute management: Ensure privacy by closing curtains/doors and draping the patient appropriately. Assess vital signs, administer prescribed antipyretics and broad-spectrum antibiotics, and prepare for potential wound exploration/debridement by the physician.
- Gold standard long-term management: Daily perineal care (peri-bottle, sitz baths), wound packing or secondary intention healing if dehiscence occurs, and close monitoring for resolution of infection and proper tissue granulation.