The action that the nurse need to take next is to Document that the dressing is intact.
What is the documentation about?
In case if the dressing is said to be soiled or there are other forms of abnormalities, wound healing is one that need not to be disrupted for a period as short as 2 days.
And as such, The action that the nurse need to take next is to Document that the dressing is intact.
See options below
1.Document that the dressing is intact.
2.Clean the wound and apply a new dressing.
3.Place a consult with the wound care team.
4.Remove the dressing to assess the wound.
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