The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage
The patient reports tenderness at the incision site. The patient's temperature is 100.5° F and the WBC is 10,500/mm3. Which nursing action should the nurse take?
a. Plan to change the surgical dressing during the shift.
b. Check to see what solution was used for skin preparation in surgery.
c. Collect supplies to culture the surgical incision.
d. Utilize SBAR to call and communicate the patient's needs to the physician.
ANS: D
Organisms enter the body in several different ways. Proper skin preparation for surgery is essential to decrease the chance of infection. The nursing assessment indicates signs and symptoms of infection. The physician needs to be called and notified of the patient's needs. SBAR—Situation, Background, Assessment, and Recommendation—can be utilized to organize thoughts and data and to provide a through explanation of the patient's current status. Changing the dressing may be a need during the shift but is not a first priority. Checking to see about the skin prep used 2 days ago may or may not be useful information at this time. Collecting supplies for culture may be necessary after talking with the physician.
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