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, including current treatment, vital signs, and laboratory results.
B) Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR) .
C) Consult the wound care nurse about the change in status and the potential for infection.
D) Check with the charge nurse about the change in status and the potential for infection.

Question

Chizoba Nnakwe · Accepted Answer

Final Answer : A, Explanation :  The patient is showing signs and symptoms associated with infection in the wound. 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 primary care provider 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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