During a morning assessment, a nurse notices a change in a patient's wound. Which of the following samples of documentation would indicate a possible infection?
1. Dressing dry and intact, small amount of serosanguineous drainage.
2. Incision line well-approximated, moderate amount of drainage noted.
3. Incision intact, small amount of pink granulation along incision line, no drainage.
4. Incision intact, moderate amount of purulent drainage, foul odor.
Question 2
A nurse notes an increase in serosanguineous drainage from a patient's incision. The most appropriate action for the nurse to take is to
1. Notify the physician of increasing amounts of clear drainage.
2. Draw a circle around the drainage and write the date, time, and initials on the dressing.
3. Change the dressing to decrease the patient's risk for infection.
4. Immediately call the laboratory and order a white blood cell (WBC) count.
Evidence-based practice: skin assessment
ROM exercises on a patient’s wrist: extension.
Roberts's Assessment, Crisis Intervention, and Trauma Treatment (ACT) model.
Landmarks for urinary assessment: The costovertebral angle
System of a patient in shock