The Wound That Smells Wrong
You are covering a 28-bed skilled nursing unit on a weekend. A 79-year-old resident, Mr. D, has a stage 3 sacral pressure injury being treated with a hydrocolloid dressing changed every 3 days per the current order. On today's change you note the wound bed has become darker, with a new foul odor, increased thin drainage, and a rim of spreading erythema. His temperature is 37.9°C, he is more confused than his baseline, and his appetite has dropped over two days. The last documented repositioning was 14 hours ago on the night shift flow sheet. The covering physician is reachable only by pager and typically calls back within 2-3 hours. The wound care nurse does not work weekends.
1. Identify the clinical and system issues in this scenario and rank them by urgency.
Read the worked answer
Clinical (highest urgency): suspected wound infection with possible systemic involvement. New foul odor, darker bed, spreading erythema, increased drainage, low-grade fever, and acute confusion in an older adult together suggest infection - and in this population, new confusion is often the earliest sign of systemic illness. This needs provider notification now, not Monday.
System/quality issues (must be addressed, but after the patient is safe):
- Repositioning documented 14 hours ago against a typical 2-hour turning schedule - a care-delivery failure that likely contributed to wound deterioration. This is a reportable quality concern, not just a charting gap.
- The dressing order (every 3 days) may no longer match the wound; an infected, heavily draining wound usually needs more frequent assessment and a different product.
- Weekend coverage gaps (no wound nurse, slow physician callback) are a system risk to plan around.
Ranking: (1) escalate the possible infection immediately; (2) get an appropriate wound assessment/order change; (3) address the turning failure and document/report it; (4) flag the weekend coverage gap for the quality committee.
2. What are your concrete actions and documentation for the next few hours?
Read the worked answer
Actions:
- Notify the provider now with a structured report (situation, background, assessment, recommendation): new odor, color change, erythema, temp, change from mental baseline, decreased intake - and request orders for wound culture if indicated, a revised dressing/treatment, and consideration of systemic evaluation.
- Interim wound care per what is safe and within standing orders - cleanse, use an appropriate dressing for drainage, avoid sealing in infection; do not improvise a treatment that requires an order without clarifying with the provider/pharmacy.
- Increase monitoring: vital signs per protocol (more frequently given fever/confusion), glucose if diabetic, hydration and intake, and a turning schedule started now with each shift accountable.
- Escalate the turning failure to the charge nurse/supervisor and ensure the resident is repositioned and offloaded immediately (appropriate support surface).
- If the provider does not respond within the callback window, escalate to the on-call medical director or nursing supervisor per policy - do not let a pager silence become a delay.
Documentation: objective wound description (size, bed color, odor, drainage, surrounding skin), vital signs with times, mental status change relative to baseline, intake, the provider notified (name, time, method, orders received), interventions and repositioning, and the escalation if any. Document facts, not conclusions you cannot support, and never backfill a turning record.