Abnormal narrative bank — focused / at-risk
Six focused abnormal narratives carrying the full necessity chain — finding, severity, comparison, risk, action, notification, and reassessment.
A1 Pressure injury deterioration with infection | Skilled assessment of a sacral pressure injury now measuring 3.2 × 2.4 × 0.4 cm with new 0.6 cm undermining at 12 o’clock, 30% yellow slough, moderate malodorous purulent exudate, and 1.5 cm periwound erythema with warmth — deterioration from a prior beefy-red granulating base and concerning for local wound infection. The wound was cleansed and redressed per order; the provider was notified at 14:10; orders for a wound culture and a topical antimicrobial were received and initiated. Infection signs and measurements will be reassessed next visit; offloading verified and reinforced. |
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A2 Wound dehiscence | Skilled assessment of a midline surgical incision found with a 3 cm separation along the inferior third, exposing subcutaneous tissue, with serosanguineous drainage — new dehiscence from a previously approximated incision. The wound was covered with sterile saline-moistened gauze, the patient kept supine with knees flexed, and the provider notified at 11:25 with orders for urgent evaluation. The patient was monitored for evisceration and instructed on activity restriction; the abdomen will be reassessed and EMS activated immediately if any viscera protrude. |
A3 Suspected osteomyelitis | Skilled assessment of a non-healing plantar diabetic ulcer over the first metatarsal head with a positive probe-to-bone and exposed bone visible at the base, malodorous drainage, and surrounding erythema — a significant change concerning for osteomyelitis. The wound was offloaded and dressed per order; the provider was notified at 09:50; orders for urgent evaluation, imaging, and laboratory studies were received. The patient was educated on strict non-weight-bearing and the limb-threatening nature of the finding, and podiatry coordination was initiated (cross-reference Diabetes overlay). |
A4 New unstageable injury / deep-tissue injury | Skilled assessment identifying a new 4 × 3 cm area of intact maroon-purple discoloration over the left heel with a boggy, cooler-then-warmer texture — a deep-tissue pressure injury not present at the last visit. The etiology was evaluated as pressure from the bed surface; the heel was floated and offloaded immediately, the provider notified at 15:30, and orders for a pressure-redistribution boot received. Repositioning and heel-offloading were re-taught to the caregiver, who return-demonstrated; the site will be reassessed each visit for evolution. |
A5 Spreading cellulitis from a wound | Skilled assessment of a lower-leg venous ulcer with new warmth, red streaking extending proximally toward the knee, increased tenderness, and a temperature of 101.2°F — new from baseline and concerning for cellulitis with possible systemic involvement. The provider was notified at 10:40; orders for antibiotics and evaluation were received and the first dose coordinated. The leg was elevated, the margin of erythema marked and timed, and the patient educated on sepsis warning signs with instruction to activate EMS for confusion, rigors, or rapid spread; temperature and the erythema margin will be reassessed next visit. |
A6 Bleeding wound on an anticoagulant | Skilled assessment of a lower-extremity wound with active bleeding saturating the dressing in a patient on apixaban — new and significant given the anticoagulant. Direct pressure was applied and maintained, the limb elevated, and bleeding controlled after sustained pressure; the provider was notified at 13:15 and bleeding-risk review initiated. The patient and caregiver were taught firm continuous pressure and to activate EMS for bleeding not controlled within the instructed time; the site and hemoglobin trend will be monitored and the Anticoagulation overlay applied (cross-reference Hematologic). |