An LPN in a long-term care facility is caring for a 22-year-old man with traumatic brain injury and a stage IV sacral pressure injury following a motor vehicle collision 6 weeks ago. He is on a scheduled wound care regimen. Baseline vital signs recorded 4 hours ago were BP 118/74, HR 82, RR 16, temp 37.1°C, SpO2 98% on room air. Today the nurse removes the old dressing using clean gloves and prepares to irrigate and repack the wound. Current vitals are BP 108/68, HR 108, RR 22, temp 38.9°C, SpO2 95%. The wound bed shows increased yellow-green purulent drainage with a foul odor. Which action should the nurse take first?
- Report the vital sign changes and wound drainage findings to the RN or provider immediately.
- Continue the irrigation and repacking using the clean gloves already applied.
- Document the increased drainage and elevated temperature in the chart and proceed to the next task, without notifying the RN or health care provider.
- Focus on measuring the wound dimensions since the surrounding skin appears intact.