When caring for the client who is 4 days post-cholecystectomy, the nurse is asked by the family if there should be so much drainage from the tube. The nurse notices that the drainage from the T-tube is 600 mL in 24 hours
Which is the appropriate action by the nurse? 1. Clamp the tube q 2 hours for 30 minutes
2. Place the patient in a supine position
3. Assess drainage characteristics and notify the physician
4. Encourage an increased fluid intake
3. Assess drainage characteristics and notify the physician
Rationale:
The T-tube may drain 500 mL in the first 24 hours and decrease steadily thereafter. If there is excessive drainage, the nurse should further assess the drainage to be able to describe it accurately and notify the physician immediately. Clamping the tube would be contraindicated. Placing the patient in a supine position and encouraging fluid intake are of no help.
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