Question

When turning the right-modified mastectomy client to her left side, the nurse notes a moderate amount of serosanguinous drainage on the bed sheets. Which nursing action is appropriate? ? A. Remove the dressing to ascertain the origin of the bleeding ? B. Milk the hemovac tubing using a continuous downward motion ? C. Note vital signs, reinforce the dressing, and notify the surgeon ? D. Recognize this is a frequent occurrence with this type of surgery

Short answer

A. Removing the dressing to determine the origin of the bleeding. B. Milking the hemovac tubing using a continuous downward motion. C. Noting vital signs, reinforcing the dressing, and notifying the surgeon. D. Recognizing that this is a frequent occurrence with this type of surgery. Answer: C. Noting vital signs, reinforcing the dressing, and notifying the surgeon.

Step-by-step solution

Analyzing the scenario

First, read and understand the given scenario. In this case, a nurse observes moderate serosanguinous drainage on the bed sheets when turning a mastectomy patient to her left side.

Evaluating Option A

Option A suggests removing the dressing to determine the origin of the bleeding. This could be considered a potential action to take, but it's not the most appropriate one, as it doesn't take into account the patient's overall condition or notifying the appropriate medical professionals.

Evaluating Option B

Option B suggests milking the hemovac tubing using a continuous downward motion. This action is to promote drainage and prevent clots in the tubing, but it may not be the most appropriate action in this case since it doesn't involve addressing the overall patient condition or notifying the surgeon.

Evaluating Option C

Option C suggests noting vital signs, reinforcing the dressing, and notifying the surgeon. This option seems to be the most appropriate since it involves monitoring the patient's condition, taking necessary measures to control the bleeding, and informing the surgeon, who would be responsible for determining if further action or intervention is needed.

Evaluating Option D

Option D suggests recognizing that this is a frequent occurrence with this type of surgery. Even if it were a frequent occurrence, it's crucial to monitor the patient's condition and inform the surgeon, making this option not the most appropriate.

Selecting the appropriate nursing action

Based on the evaluation of each option, Option C (Note vital signs, reinforce the dressing, and notify the surgeon) is the most appropriate nursing action in this scenario. It addresses the patient's condition and communicates with the appropriate healthcare professional if needed.

Key concepts

Postoperative Care

Postoperative care plays a crucial role in ensuring a patient's smooth recovery following surgery. After a procedure, the body needs time and support to heal properly. Patients require dedicated care to manage their pain and prevent complications.
During this phase, nurses are tasked with:

• Monitoring the patient's vital signs
• Assessing the surgical site for any signs of infection or excessive bleeding
• Managing pain using prescribed medications
• Educating the patient and family about home care and follow-up appointments

Effective postoperative care involves being observant and responsive to any changes in the patient’s condition. It also involves maintaining clear communication with the surgical team to address any emerging concerns.

Mastectomy Patient Care

When caring for a patient who has undergone a mastectomy, special considerations are required. This type of surgery involves the removal of breast tissue and is typically performed to treat or prevent breast cancer. Patients may have additional emotional and physical needs.
Key aspects of mastectomy care include:

• Managing pain and discomfort
• Providing emotional support and counseling
• Promoting mobility while ensuring arm activity is moderated
• Preventing upper limb lymphedema by instructing proper arm care

Post-mastectomy, patients might also have drains in place to remove excess fluid. Nurses play a vital role in teaching patients how to care for these drains upon discharge.

Drainage Management

Effective drainage management is essential to prevent fluid accumulation and reduce the risk of infection following surgical procedures like a mastectomy. Patients might have a hemovac or other types of drains to collect fluids effectively.
Here are some important considerations:

• Ensure that the drains are secured and not tangled
• Regularly check the amount and type of drainage
• Use aseptic techniques when handling drains to prevent infections
• Educate the patient on how to monitor and empty the drains

Instructing patients on when to contact healthcare providers — for things like significant increases in fluid collection or changes in color and odor — is also crucial for effective home drainage management.

Nursing Assessment

An accurate and comprehensive nursing assessment is the foundation of effective care, especially post-surgery. It involves collecting information about a patient's physical condition, emotional state, and response to treatments.
Important components of a nursing assessment include:

• Checking vital signs to identify any early signs of distress
• Assessing the surgical site for signs of infection, like redness or unusual swelling
• Evaluating drainage output to ensure it remains within expected ranges
• Understanding patient’s pain levels and assessing the need for medication adjustments

Frequent assessments allow nurses to provide timely interventions and improve outcomes for patients recovering from surgery. Effective communication of assessment findings with the surgical team is also critical in ensuring comprehensive care.