A nurse is caring for a client in a wound center. Exhibits Click to highlight the findings that indicate therapy has been ineffective. To deselect a finding, click on the finding again. Nurses' Notes Today: Client presents for evaluation of wound vac therapy that was applied to surgical wound on their left knee 1 week ago. Client rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. Respirations even and nonlabored. Heart rate regular and fast. Abdomen soft and nondistended. Left knee wound vac dressing removed. Left knee wound is 3 cm by 2 cm with 1 cm depth. Wound bed vascular with some approximation of the edges. Mild purulent drainage noted.

Rationale for Correct Choices Pain rating of 8/10 with no relief from pain medications: Increased or uncontrolled pain can indicate infection, inflammation, or ineffective wound healing. The lack of pain relief suggests the current wound vac therapy is not adequately addressing the underlying issue. Wound size increased from 2 cm × 2 cm to 3 cm × 2 cm: Wound enlargement indicates delayed or ineffective healing. Effective wound vac therapy should reduce wound size and promote closure; an increase in size signals treatment failure. Mild purulent drainage noted: Presence of purulent drainage suggests infection or poor wound healing. Effective negative-pressure therapy should promote a clean, granulating wound bed without signs of infection. Rationale for Incorrect Choices Wound bed vascular with some approximation of the edges: This finding suggests that some healing is occurring. A vascular wound bed indicates good blood supply, which is necessary for tissue repair, and partial approximation of edges shows that some granulation tissue is forming and the wound is attempting to close. Respirations even and nonlabored, abdomen soft and nondistended, heart rate regular: These systemic findings suggest the client is stable overall. They indicate that there is no acute systemic compromise from the wound,