Observe colour and amount of drainage. If excessive, apply direct pressure. Obtain vital signs. Notify health care provider of findings.

Correct

Notify health care provider, who may consider drain placement or alternate dressing method. Correct

Monitor patient for signs of infection, for example, fever, increased white blood cell (WBC) count, purulent drainage. Notify health care provider. Obtain wound cultures as ordered. Correct

Provide additional teaching and support. Obtain services of home care facility as needed. Correct

Observe wound for increased drainage, dehiscence, or evisceration. Cover wound with sterile moist dressing, if necessary. Instruct patient to lie still. Notify health care provider.

Definitions

(1) Patient or caregiver is unable to perform dressing change

(2) Patient reports a sensation that "something has given way under the dressing."

(3) Wound bleeds during dressing change

(4) Wound appears inflamed and tender, drainage is evident, or an odour is present

(5) Wound drainage increases, requiring frequent dressing changes