A home health nurse, while in the home to change a decubitus dressing, notices that the wound has a musky odor and is weepier than the previous visit, 2 days earlier. Place the following nurs-ing interventions in order of priority from most to least
(Separate the letters with a comma and space: A, B, C, D.)
A. Contact the case manager.
B. Assess the patient's entire skin and vital signs and be prepared to describe the wound findings.
C. Cleanse the decubitus area well and redress the wound.
D. Chart the appearance of the decubitus completely.
D. Assess the patient's mobility.
B, C, E, D, A
The decubitus finding is important to communicate to the case manager but not until the nurse at the bedside has fully assessed the patient, signs and symptoms, vital signs, and other areas of change that need to be promptly communicated. Then the case manager will be able to give di-rections for further care.
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