Question

1. What should the nurse do if the abdominal dressing was soaked with sanguineous drainage?

2. Describe serous, serosanguinous and sanguineous draining.

3. What would be focused assessment of a postoperative partial gastrectomy patient include?

Answer 1

Ans 1 sanguineous drainage is fresh bloody exudates ., Mostly just after surgery or next day to surgery .

Nurse should assess the size of dressing , colour of soaked dressing ,weight the soaked drainage and report to the physician . About the weight , color , size of dressing so that quantity of blood loss can be assessed and if any prognosis of complications , complication can be prevented As hypovolemia .

Nurse should also assess dressing every 2-4 hours in first 24 hours. , Assess both incisional or dressing site And change the dressing.

Que 2.

1) Serous : it's mostly clear or slightly yellow thin plasma that is just a bit thicker than water. This drainage contains sugar white cells , protein , and other chemicals that are important in healing .Often apears .48-72 hours after surgery . This drainage mostly occur in venous ulceration and partia- Thickness wound . Some times exudate becomes pink because of small number of RBC but its normal in early stage of healing.

2 ) Sanguineous : this is fresh bloody exudate which appears when skin is breached whether fro surgery of any injury . Drainage is bright red in colour and some what thick in consistency like syrup ..

Its mostly seen during angiogenesis in both full thickness or deep partial thickness wounds . This Normally occur inflammatory phase of wound healing . This drainage has features .of added plasma which make the run off appear pink in color.

LARGE AMOUNT = suspected hemorrhage

Bright drainage = . indicates fresh bleeding

Darker drainage = indicates older bleeding.

3) serosanguineous :thin watery drainage that is blood tinged. its appears when wound is trying to heal and may have pale red or pink color. Serosanguineous drainage. May appear as clear liquid swirled with red blood. This change appearance depend on how much clotted blood is mixed in with blood serum. This is sign of healing .

If wound give off serosanguineous discharge , may be due to . Damaged capillaries .

Old drainage may dry and attach dressing .or bandage and damage. Capillaries close to skin. When pulled of.

Que 3 immediate post operative assessment is

A) Airway and oxygenation

B) Breathing and ventilation

C) Circulation and shock management

D) Any Disability

E) Exposure and examination

FOCUSED ASSESSMENT

1) Assess position and patency of NaG tube connecting it to low suction to drain..Ng tube placed in stomach to avoid disruption of gastric suture lines and ng should be secured well . patency must be maintained to keep the the stomach decompressed , reducing pressure on suture.

2) assess color , amount ,odor of gastric drainage . Initial . Drainage is bright red. It becomes dark then clear or greenish. Yellow over the first. 2-3 days . , amount or odor may indicate complications such as hemorrhage , intenstinal obstruction or any infection. Any change in parameters should be noted.

3) maintain IV. Fluid While NG tube . suction is in place . If not maintained the client is at risk of dehydration. , Imbalance of electrolyte ., Metabolic alkalosis.

4) Provide antibiotics therapy or antacid as prescription.

5) monitor bowel sounds and change in peristaltic movement .or abdominal distension .

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