The nurse changes the dressing of the patient with a sacral pressure injury. Upon removal of the dressing, the nurse notes yellow drainage on the dressing with a fruity odor. Place the nurse’s actions in the correct order from first to last.

Discard the dressing after noting amount of drainage , Cleanse the wound with tap water, Assess for further signs of infection in the wound, Take cultures of the center of the wound. The wound that has a fruity odor upon removal of the dressing may be infected. However, a wound is never assessed for signs of infection until after the old dressing is discarded and the wound is cleansed. Therefore, the nurse first discards the dressing after noting the amount of drainage for documentation. Then, the wound is gently cleansed with tap water. The nurse then assesses for further signs of infection in the wound – persistent smell, inflammation, purulent drainage, etc. After this assessment, it is appropriate to culture the wound.

The nurse changes the dressing of the patient with a sacral press...

Category: Physiological Adaptation
Difficulty: 10

Topics: Delegation, Prioritization and Leadership Infection Inflammation Laboratory Studies Nursing Interventions Tissue Integrity

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