The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
a. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results.
b. Notify the charge nurse about the change in status and the potential for infection.
c. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR).
d. Notify the wound care nurse about the change in status and the potential for infection.
ANS: A
The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.
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