Question

The nurse is assessing a patient who just returned from a bowel resection 1 hr ago. The nurse notes a dressing of the suture line that is wet with sero-sanguineous drainage. The nurse should initially:

a. perform a sterile dressing change
b. document and report the wet dressing to the charge nurse
c. reinforce the wet dressing and document
d. place a towel on the bed and turn the patient to the operated side

Answer 1

The initial step the nurse should take is to reinforce the wet dressing and document the condition. Subsequently, the nurse should report to the charge nurse or the attending physician for further instructions. Proper documentation and communication are essential for postoperative care and monitoring.

Step-by-step explanation:

The nurse should initially reinforce the wet dressing and document the condition. This is a common practice after surgery to maintain the integrity of the surgical site until further assessment and interventions can be made. If there is excessive drainage or other signs of potential complications, it is essential to report the findings to the charge nurse for further instructions or intervention as needed. The current dressing should only be changed under sterile conditions and after evaluating the necessity and safety of doing so, often with an order from the attending physician. Immediately placing a towel and turning the patient to the operated side may cause more harm and is not usually done without specific reason.

Documenting the condition of the dressing and any interventions performed is critical for ongoing patient care. This ensures continuity and helps in monitoring the progression of healing or the emergence of any complications postoperatively. The charge nurse or the surgeon may need to decide on advanced care options depending on the findings.