Which assessment information given upon admission directs the nurse to assess for pressure injuries? (Select all that apply)

A. Hemorrhage: This complication involves acute, profuse blood loss from damaged vascular structures within the surgical site. Clinical manifestations typically include hematoma formation, hypovolemia, or bright red sanguineous output. The presence of intact edges and serosanguinous fluid contradicts active arterial or venous bleeding.

B. Wound infection: Pathogenic colonization triggers an inflammatory response characterized by localized erythema and edema around the incision. Increased serosanguinous or purulent exudate reflects the body's immunological reaction to microbial invasion. These clinical markers are classic precursors to localized sepsis or abscess formation.

C. Wound dehiscence: This mechanical failure involves the partial or total separation of previously approximated wound layers. While serosanguinous drainage can precede this event, the question specifically states the incision edges remain intact. Therefore, the structural integrity of the wound has not yet been compromised.

D. Fistula development: This represents the formation of an abnormal passage between two internal organs or an organ and the skin. It usually results from chronic inflammation, malignancy, or severe infection rather than acute post-operative edema. The localized symptoms described are more indicative of a superficial or deep infection.

A. Document the refusal and its management: Documentation is a legal requirement that follows the intervention but does not constitute the immediate priority. The nurse must first engage in clinical inquiry to address the client's concerns or misconceptions. Recording the event occurs only after all attempts at education and assessment are exhausted.

B. Notify the healthcare provider of the patient's refusal: While the prescriber must eventually be informed of deviations from the treatment plan, this is not the first step. The nurse should first gather pertinent data regarding the refusal to provide a comprehensive report. Immediate notification without assessment is premature and inefficient.

C. Speak with the client to determine the reason for the refusal: The primary responsibility is to respect patient autonomy while ensuring informed consent or refusal. Identifying specific barriers, such as fear of side effects or lack of understanding, allows the nurse to provide targeted education. This assessment phase is essential for therapeutic communication.

D. Identify to the client the irrational reason for refusing part of the therapy: Labeling a patient's concerns as "irrational" is non-therapeutic and damages the nurse-client relationship. It violates the principle of respect and may increase the client's defensiveness. Education should be objective and supportive rather than judgmental or confrontational.