What action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the post-anesthesia care unit who had an abdominal cholecystectomy?
Answer:
First, the nurse should assess the wound with serosanguineous drainage, notify the surgeon, and monitor the patient’s condition. Documentation and communication with the healthcare team are critical for initiating appropriate interventions.
Explanation:
The first action a nurse should take upon observing serosanguineous drainage on the abdominal dressing of a post-cholecystectomy patient is to assess the wound and the amount of drainage and notify the surgeon of the findings. The presence of serosanguineous drainage could indicate a wound infection or other complications such as hematoma or dehiscence. It is critical that the nurse documents the findings and monitors the patient’s vital signs and overall condition. Assessment involves examining the wound’s characteristics, measuring the drainage, and checking for signs of infection, including redness, warmth, increasing pain, or discharge. In light of the case study where the patient already shows signs of infection, these findings should be communicated immediately to the healthcare team for appropriate interventions, which may include antibiotics, further diagnostic tests, and potentially surgical intervention for severe infections like gas gangrene.
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