The client is 90 minutes postoperative after shoulder surgery and the Hemovac drain contains 400 ml of serosanguinous fluid since surgery. Which should the nurse do first?
1. Collaborate with the surgeon.
2. Monitor the Hemovac drainage.
3. Irrigate drain with sterile fluid.
4. Attach a larger Hemovac drain.
1
1. The nurse collaborates with the surgeon about the client with 400 ml of serosanguinous drainage 90 minutes after shoulder surgery because 400 ml is an excessive amount of drainage, especially for a shoulder and is likely to cause hypotension, dizziness, tachycardia, and oliguria in the client.
2. The nurse should continue to monitor the drainage; however, because the volume of drainage is excessive, the more important action is to collaborate with the surgeon to resolve the bleeding.
3. The nurse avoids irrigating the surgical drain to decrease the risk of infection in a fresh postoperative site. In addition, surgical drains are not designed for irrigation.
4. The Hemovac is an integrated unit including the drainage container and attached drain that is placed in the surgical site at the conclusion of a procedure; to change a Hemovac, the provider replaces the tubing and container. This is not a nursing function.
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